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1 CODE: 4185
LISA A. YOUNG, CCR #353
2 Peggy Hoogs & Associates
345 Marsh Avenue
3 Reno, Nevada
COURT REPORTER
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9 NEVADA STATE BOARD OF MEDICAL EXAMINERS
10 BOARD MEETING
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12 Conference Room at the Offices of
13 the Nevada State Board of Medical Examiners
14 Friday, March 12, 2004
15 9:00 a.m. - 4:00 p.m.
16 Reno, Nevada
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25 Reported by: LISA A. YOUNG, CCR #353
PEGGY HOOGS & ASSOCIATES (775) 327-4460
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1 APPEARANCES
2 PRESENT IN RENO:
3 Cheryl Hug-English - President
Jaculine C. Jones - Vice President
4 Charolette Bible - Assistant Chief Deputy Attorney
Stephen D. Quinn, J.D. - Deputy General Counsel
5 Richard J. Legarza, J.D. - Deputy General Counsel
Donald Baepler, Ph.D., D.S.
6 Joel Lubritz, M.D.
Marlene J. Kirch, Public member
7 Sohail U. Anjum, M.D.
Robin Titus, M.D.
8 Stephen K. Montoya, M.D.
Javaid Anwar, M.D.
9 Laurie Munson - Deputy Executive Secretary
Larry D. Lessly, J.D. - Executive Secretary.
10 Special Counsel
Drennan A. Clark, J.D. - Deputy Executive Secretary
11 Special Counsel
Lynnette L. Krotke - Chief License Specialist
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13 PRESENT IN LAS VEGAS:
14 Edwin Kingsley, M.D. - President, Clark County Medical
Society
15 Don Havens, M.D. - Clark County Medical Society
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PEGGY HOOGS & ASSOCIATES (775) 327-4460
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1 RENO, NEVADA; FRIDAY, MARCH 12, 2004; 9:00 A.M.
2 -o0o-
3 PRESIDENT HUG-ENGLISH: I'd like to call this
4 meeting of the Nevada State Board of Medical Examiners
5 to order.
6 I just want to confirm that -- Are we on down
7 in Las Vegas? Can you hear us? No. My button is on.
8 Are we on in Las Vegas, Laurie?
9 MS. MUNSON: We just need to unmute. They are
10 not on, though. They can hear us.
11 PRESIDENT HUG-ENGLISH: Can you hear us down
12 in Vegas?
13 MR. LESSLY: They can't answer us.
14 PRESIDENT HUG-ENGLISH: Okay. Thank you. And
15 welcome.
16 Okay. We do have a very full agenda today and
17 tomorrow. And I see that we have lots of public members
18 here that when we get to certain agenda items please let
19 us know what you are going to comment about.
20 First thing is approval of the minutes from
21 our December meeting. Is there any discussion about the
22 minutes or additions or changes?
23 If not, I would accept a motion to approve the
24 minutes.
25 DR. LUBRITZ: So noted.
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1 MS. KIRCH: Second.
2 PRESIDENT HUG-ENGLISH: There is a motion and
3 a second to approve the minutes from our December board
4 meeting. All in favor?
5 THE BOARD: Aye.
6 PRESIDENT HUG-ENGLISH: Opposed? The minutes
7 are approved.
8 Next item on the agenda is under personnel and
9 consideration and discussion for additional staff
10 requirements.
11 And, Larry, I believe you are going to address
12 this.
13 MR. LESSLY: Thank you. There are two aspects
14 to this agenda item, one short-range and one long-range.
15 Let me address the short-range, and then I
16 will have Tony address the long-range.
17 We have added Mr. Quinn to the staff as deputy
18 attorney general -- deputy attorney counsel, not deputy
19 attorney general.
20 He and Mr. Legarza are both working full-time
21 and busy full-time. It is apparent when Mr. Legarza
22 retires we are going to need another attorney.
23 It is also apparent that we need to bring that
24 attorney in now. So we are asking for authority to hire
25 a deputy general counsel immediately to come on board as
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1 soon as possible.
2 We have someone in mind, without telling you
3 who that is at this point, but we would look for someone
4 with less experience than Mr. Quinn, someone who would
5 be with the board for a lengthy period of time and would
6 have an opportunity to practice in this field.
7 So we would request, first of all, for
8 authority to retain that person immediately.
9 And I will let Tony talk about the
10 investigators and the licensing specialists which are
11 more long-range.
12 MR. CLARK: At the present time our licensing
13 specialists are over-engaged. And they have currently
14 52 application files that they have not been able to
15 open and start working yet. And they are all carrying
16 40 or more applications that they are working actively.
17 They need another licensing specialist. What
18 we would anticipate is hiring someone as soon as
19 possible, bringing them on at an entry level salary of
20 $32,000 and then considering if that person works out
21 raising the salary at six months or considering raising
22 the salary at the six-month level.
23 We do not need new equipment and would not
24 need any additional office space to house that person.
25 It also appears because of an increase in
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1 complaints and in administrative work in handling
2 complaints and doing more notifications that we are
3 going to need a couple more investigators.
4 I would not propose that they come on board
5 until the beginning of the new fiscal year, July 1st.
6 They would start out essentially at $38,000 each and
7 then be reviewed at six months.
8 What we would like to do is get your approval
9 to hire on January -- excuse me on July 1st so that Doug
10 Cooper, head of investigations, can start advertising
11 and conduct some interviews.
12 That will require some additional space
13 because there is not space in the current office area
14 where investigators are located. And that would require
15 two additional computers as well, one for each of them.
16 I might add, somewhere down the line we should
17 probably upgrade the computers for the deputy general
18 counsel and for a new licensing person. We have
19 computers there, but they are old and slow and they need
20 to be upgraded at some point.
21 There is office space in the building
22 currently available down on the first floor right across
23 the hall from where the license specialists are working.
24 It would accommodate all of the investigators.
25 So if it is the board's feeling that we should consider
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1 and should hire two additional investigators commencing
2 July 1st, I would like authority to negotiate with the
3 building manager to take that space so it can be
4 converted and cleaned up and utilized by investigators.
5 PRESIDENT HUG-ENGLISH: Turn on your button.
6 DR. MONTOYA: For the need for licensing
7 specialist is it because of the increased number of
8 applicants that came into the State, or is it because of
9 the depth of the investigation you have to go through on
10 each applicant and that is slowing the process down?
11 MR. CLARK: It's a little of both, but more
12 because we are having more applicants. Tremendous
13 number of applicants are now applying for licensure in
14 Nevada.
15 They are doing a little more background
16 investigation, but primarily it's because of the number
17 of applications that are coming into the process.
18 DR. MONTOYA: On the investigator's side, it's
19 more or less the same question, are we getting more
20 complaints? Is it more complaints per capita, or is it
21 we are just getting more complaints because of the
22 number of people we have?
23 MR. CLARK: We are getting more complaints
24 because I think of the number of people we have. And
25 it's partially due to the legislature doing away with
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1 the medical dental processing panel. So that anybody
2 can just go file a malpractice suit. And in order that
3 none of those fall through the cracks, we have to have
4 the investigators take a look at them to see if there is
5 any validity to them.
6 So that has increased the case load of each of
7 the investigators.
8 Around the sister states most investigators
9 handle between 30 and 50 files at a time. And our
10 investigators are each handling more than 100.
11 DR. MONTOYA: That's currently why we have two
12 investigative committees instead of just one. And each
13 one has to read boxes and boxes of material each
14 session.
15 MR. CLARK: That's correct. And it's because
16 more complaints are coming in.
17 DR. MONTOYA: And it's because you have to
18 generate all this paperwork for us to see. So it takes
19 a lot of time. I understand that. Thank you.
20 DR. LUBRITZ: I'm sorry. May I ask some
21 questions of Doug Cooper?
22 MR. CLARK: Yeah, sure.
23 DR. LUBRITZ: Will two investigators assist
24 you in what you feel is adequate coverage for the
25 current case load?
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1 MR. COOPER: Yes, I believe so. Right now
2 after the March board we anticipate if we close the
3 amount of cases we are going to suggest we close, our
4 per investigator case load will be 107 cases.
5 If we took that figure which is, of course,
6 the most important figure and add two investigators, our
7 cases load would be 71 cases. I think that is
8 manageable.
9 DR. LUBRITZ: Roughly what would it cost us to
10 get the new computers and all that we need?
11 MR. CLARK: Computers are about $2,000 each.
12 We are going to need four.
13 MS. MUNSON: Four or five.
14 MR. CLARK: Four to plug the equipment in, but
15 that equipment costs $200. And then we can add up to 24
16 and we will have plenty of space for that. And the
17 floor space down there is about 1150 square feet, and
18 the price is about $1.10 per square foot so it's about
19 $1265 a month for additional space.
20 DR. LUBRITZ: Thank you.
21 DR. BAEPLER: What about the budget? The
22 budget is dwindling in terms of reserves. Ever since we
23 lowered the fees for licensing, the budget has -- the
24 reserve fund has shrunk considerably. There is enough
25 latitude in the budget to accommodate all of this, I
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1 assume.
2 MR. CLARK: There is enough in the budget to
3 accommodate both the purchase of some new computer
4 equipment in the equipment account and the personnel
5 account to cover one licensing specialist, deputy
6 general counsel, and at the first of the year when we go
7 or first of fiscal year when we go into the new fiscal
8 year to handle two more investigators so, yes.
9 DR. BAEPLER: I think, you know, whenever
10 there is space available, we have to grab it. It's not
11 always available. And I think the need for a new
12 licensing specialist is good news.
13 And I'm delighted to hear that people want to
14 move to the state to practice medicine. I hope it's not
15 just a momentary blip but it's reached a new plateau.
16 So I would move that we authorize the request
17 presented by both of you gentlemen.
18 MS. JONES: I second it.
19 PRESIDENT HUG-ENGLISH: There is a motion and
20 a second to approve the increased staff requirements of
21 a new deputy general counsel, two investigators and a
22 new licensing specialist. Any further discussion?
23 All in favor?
24 THE BOARD: Aye.
25 PRESIDENT HUG-ENGLISH: Opposed?
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1 Chair votes in favor of the motion. Motion
2 carries.
3 I think it is clear that those staff members
4 are really needed, and I just want to reemphasize how
5 hard the current staff members are working under very
6 difficult circumstances. And their case load is just
7 tremendous so I think this is definitely needed and will
8 hopefully be a help.
9 Okay. We are going to skip to agenda item
10 seven and that is our committee report to review the
11 public service announcement program. And, Dr. Montoya,
12 I think you are going to address that.
13 DR. MONTOYA: We met last month in Las Vegas
14 with the Nevada communications, and we are a
15 comprehensive campaign to get the word out about what
16 the State Board of Medical Examiners does, who we
17 represent, et cetera.
18 We met with the Nevada Broadcasters
19 Association. It was a very fruitful meeting. They
20 listened very carefully to what we had to offer. It was
21 myself, Marlene, Tony, were all there. And we came up
22 with several things that we wanted to accomplish.
23 We wanted to make sure that the public
24 understood what our mission was, that our doctors were
25 professional, honorable, and we had plenty of good
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1 doctors here in the state of Nevada. And we wanted to
2 keep them here in Nevada.
3 We wanted to come up with ways to make the
4 website more user friendly and more available.
5 What we came up with -- actually, we didn't
6 come up with. They took the ideas, and they came up
7 with these scripts for us. I was just given the scripts
8 today. And we are currently reviewing scripts for
9 television spots.
10 We are getting a lot of bang for the buck out
11 of the Nevada Broadcasters Association. They aired
12 these commercials quite a bit. And it seems to me it's
13 a money well spent in a particular endeavor.
14 We don't have anything concrete yet. As soon
15 as we review all of these scripts and narrow them down
16 and make sure they fulfill what we feel is the board's
17 mission, we will present it to the board and take it
18 from there.
19 DR. BAEPLER: The current TV or ads would be
20 phased out?
21 DR. MONTOYA: Yes, absolutely.
22 MR. CLARK: And each of the board members has
23 a copy of the scripts proposed and the proposed campaign
24 and cost furnished by Nevada Broadcasters Association in
25 the papers that were handed out this morning.
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1 So perhaps at your leisure or on breaks you
2 could take a look at some of those and give Dr. Montoya
3 and Marlene and me some feedback on what you think.
4 PRESIDENT HUG-ENGLISH: I think that that's a
5 great idea. I think also we have later this morning
6 Mr. Fisher. I don't think he is here yet.
7 MR. CLARK: He is going to be in Las Vegas.
8 PRESIDENT HUG-ENGLISH: Okay. We have
9 consideration of the continuation of the Broadcasters
10 Association contract. And so he will have a little
11 report for us, I think, later this morning.
12 But I appreciate, Steve, you and Marlene being
13 willing to look at this. And I think that it's great to
14 see that we have already gotten some scripts to review.
15 And I think that we don't really have to -- well, Tony
16 or Larry, correct me, when does our current contract
17 expire with the Broadcasters Association?
18 MR. LESSLY: March 31st.
19 PRESIDENT HUG-ENGLISH: So we really do need
20 to take action in this meeting in some way to continue
21 that.
22 MR. LESSLY: Yes.
23 PRESIDENT HUG-ENGLISH: Okay. Now these
24 scripts that have been presented, would this be what
25 they see to go forward if we continue the contract?
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1 These are new scripts that would be incorporated into
2 those public service announcements?
3 MR. CLARK: Yes. And those scripts, and they
4 would have people like Senator Richard Bryan, Senator
5 Bill Raggio, Joel Crowley in the north. Dr. Montoya had
6 a recommendation for a doctor in the south who would
7 probably do those in Spanish who is the chief at one of
8 the hospitals.
9 DR. MONTOYA: Yes, Dr. Tony Alamo.
10 MR. CLARK: So we would use particularly
11 people who are known in the north for the northern
12 campaign and people who are known in the south for the
13 southern campaign and hopefully some of the people who
14 are known in the other 15 counties for people in the
15 outlying cow counties would know them. That was a term
16 of art, Robin.
17 PRESIDENT HUG-ENGLISH: So I guess we really
18 have two decisions to make as a board at this meeting.
19 One would be whether or not we want to continue the
20 contract with the Broadcasters Association and then the
21 second is whether or not -- and I know that all of us
22 are seeing this for the first time -- but whether these
23 are scripts we want to go forward with right now because
24 our contract does expire at the end of this month.
25 I would suggest that during our first break
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1 that the board members kind of take a look at these
2 scripts and certainly we could make a decision to go
3 forward with the contract and also make provisions for
4 this. I don't think we necessarily have to commit to
5 these exact formats but --
6 MR. CLARK: And this is only the first shot at
7 the scripts.
8 DR. MONTOYA: I wanted to re-emphasize that we
9 are not married to these scripts. This is just the
10 first shot. There will be multiple modifications I'm
11 sure.
12 MS. KIRCH: When we had the meeting, they had
13 their creative people there too. We gave them some
14 ideas, agreed we would look at the preliminary scripts.
15 If we had other suggestions, we could go back to them.
16 So they are very willing to work with us.
17 DR. LUBRITZ: Cheryl, I notice it says the
18 Nevada Broadcasters Association with board approval and
19 support for doing a 12 month campaign for $72,000 for 12
20 months worth of production for 15,000 for a total of
21 87,000. Do you know what we are currently paying?
22 MR. LESSLY: Five thousand dollars a month.
23 DR. LUBRITZ: That's the number that stuck in
24 my mind. So we are increasing that by $12,000 for the
25 annual budget in addition to a $15,000 production.
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1 I personally at a time when we are having a
2 decrease in reserve -- when we are having a decrease in
3 our reserve to take on more. My question is is that
4 also a negotiable figure on the increase which would be
5 $12,000 and, of course, there is production fees and I
6 understand that. And that was my only comment.
7 MR. CLARK: I'm sure it is, Dr. Lubritz. I'm
8 sure it is negotiable. The first time that any of us
9 saw this proposal was when it came on e-mail yesterday.
10 We were laboring under the idea that we would
11 continue on at 5,000 a month or 60,000 a year. And this
12 was an upgrade in their proposal to us.
13 MR. LESSLY: If you are going to decide to
14 renew this contract effective April 1st, for three more
15 months, renew it at the $5,000 figure. We have some
16 lead time involved to have these scripts and develop
17 this new program.
18 MR. BAEPLER: My own opinion is I would vote
19 to continue the program only if those old ones were
20 going to be scrapped and we had some new ones in there.
21 I'm really getting tired of the old ones.
22 MR. LESSLY: We are going to have to look at
23 the old ones for three more months.
24 MR. BAEPLER: No, I realize that.
25 PRESIDENT HUG-ENGLISH: We will get more
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1 information, I think, later this morning when Mr. Fisher
2 is here to give his presentation. But I think that's a
3 good point, Joel.
4 I'm going to skip again to agenda item 15
5 under our reports and I would like -- we have some
6 members of the diversion program here. And I guess we
7 have some spare chairs up here to have you come forward.
8 Mr. Rosencrantz is here and others. So we
9 will go ahead.
10 MR. ROSENCRANTZ: I'm Arne Rosencrantz with
11 the Nevada Health Professionals Assistance Foundation.
12 I was here in December, and there was some
13 questions about our continuity and how we were going to
14 continue. But we have made some great strides, and I'm
15 really proud and happy to be here today.
16 First, I would like to introduce our
17 president, Tim Coughlin. Dr. Coughlin from Reno, Roger
18 Belcourt is a board member. Dr. Belcourt is from Reno
19 as well.
20 Our medical director and executive director
21 who took over after Dr. Rueckl and Carol Bowers left,
22 and he is doing this on an interim basis. He has been
23 terrific. He has volunteered his time and worked really
24 hard to put our records and get this organization
25 straight. He has done a great job. Dr. Bradley
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1 Thompson from Las Vegas. I'm really glad to have Brad
2 on board.
3 And our special guest is Dr. Peter Manski and
4 I think the CVs have been passed out already.
5 Dr. Manski we are in negotiation and contract
6 with him now and I will just turn this meeting over Tom
7 Brad -- Dr. Thompson and let him tell you about what the
8 foundation has done.
9 DR. THOMPSON: Thank you for having us here
10 today. We are now in our ninth year and Nevada Health
11 Professionals Assistance Foundation is going to serve
12 Nevada, I think, as well as any of the states doing a
13 comparable fashion.
14 As you know or many of you know, Dr. Rueckl
15 resigned last year effective at the end of '03 due to a
16 personality conflict with Sunrise Hospital.
17 And Carol Bowers who was the executive
18 director for the last four years also resigned to take a
19 position back at Talbot Recovery Center in Atlanta.
20 Everybody else took two steps back. And I
21 sort of ended up doing this to keep the foundation
22 together while we are looking for a new director. And I
23 think hopefully we have found one.
24 And after we went through about six different
25 states -- And really we did a national search -- we
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1 unanimously selected Dr. Peter Manski who is the current
2 medical director of the entire New York program.
3 Our target date for the assumption of duties
4 given plus or minus -- you know, it's our target date is
5 May 17th for his assumption of duties.
6 At that time it is our plan to combine both
7 the executive and the medical directorships because
8 Dr. Manski is a psychiatrist.
9 And I think it's redundant to have a medical
10 director. Plus, we can combine the fees of both Carol
11 and Victor to one salary. That made us more marketable.
12 That's how we were able to do this.
13 However, Dr. Manski, however, will not be able
14 to practice medicine until he gets his license. I'm
15 sure you will all agree.
16 So I will continue to be the medical director,
17 I guess, until Dr. Manski's license goes through. And
18 then we only need one position. So that will be
19 helpful.
20 I don't know if you are interested currently,
21 let me know if you are, in the competition of who our
22 clients and participants are. If you are interested in
23 that data right now -- I'm going to make this report
24 available if anybody wants a break down of north and
25 south physicians, PAs and RTs, or whether you want to
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1 look that way. I know there is a time --
2 DR. LUBRITZ: Just, quickly, how many do you
3 have in the program just --
4 DR. THOMPSON: Sixty-three active.
5 DR. LUBRITZ: North and south?
6 DR. THOMPSON: Yeah, that's everybody total.
7 DR. LUBRITZ: What is the mix on that,
8 Dr. Thompson?
9 DR. TITUS: I think we are interested.
10 DR. THOMPSON: I will be happy to do that.
11 There are 49 physicians. This is both north and south.
12 Fifteen from the north and 29 from the south.
13 There are five who are out of state. Meaning
14 they are either doing local tenants here or their
15 applications are pending. I see one of them on the
16 agenda for later today. Actually, we are starting a
17 contract already. So that's where the other five come
18 from.
19 There are 10 respiratory therapists, two in
20 the north and eight in the south.
21 There are two physicians assistants both in
22 the south. Now these are just the active contracts.
23 All right. That doesn't include the -- we are still
24 advocating for -- they have completed their six months,
25 two year or five year contracts which is the majority of
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1 it. So there are lots and lots of others currently
2 being monitored.
3 We are pleased to report that we are
4 financially solvent. We have in reserve about two and a
5 half months of operating expenses and liquid reserve.
6 Though, we are not exactly living paycheck to
7 paycheck, we are going to have some start-up costs for
8 Dr. Manski. And we have had some costs with the
9 interviews but we are doing okay. I have already taken
10 steps to increase our reserve.
11 We are getting a little tougher with the
12 clients. We are also increasing the client fees a
13 little bit. We are having -- I have already put in
14 requests and have verbal commitments from Sunrise
15 Hospital. And also the Nevada Hospital Association has
16 given us a verbal commitment, but they haven't specified
17 an amount yet. In the past it has been usually in the
18 range of 30 to $50,000.
19 We currently have a verbal commitment which
20 will be firmed up next month from the osteopathic boards
21 who contracts with us. I did not include that in the
22 stats you have heard.
23 And then we may even at some point get support
24 from the medical societies that will be if we get a
25 strong relationship going with the medical societies
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1 they might even help us as well.
2 Further possibilities include, you know, we
3 may approach the dental board for some contracts with
4 them.
5 We have already received an individual
6 donation. And we may consider formalized contracts with
7 the hospitals themselves because we do a lot of work
8 that doesn't come through this. You know, it comes from
9 the hospital programs themselves with mostly behavior
10 and chemical problems.
11 And we have Dr. Manski, should our contract
12 come through, who has had a lot of fund-raising
13 experience in his years in New York state.
14 I think that in the brief tenure since Carol
15 left I have been very happy with the relationship with
16 you folks and your availability for questions and
17 comments and I hope that that continues to be strong. I
18 mean, your staff has been fantastic.
19 Less secure is our relations with the
20 individual hospital staffs. They tend to be a little
21 more maverick and independent. Carol did some great
22 work in forging ties that are particularly in the south.
23 And I -- my plan is to go in and introduce Dr. Manski to
24 the individual hospital staffs, the executive
25 committees, and administrations and provide him -- he
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1 doesn't know this yet -- and provide him with the
2 availability to speak to staffs as they deem it
3 necessary.
4 Also, Dr. Manski we would like to encourage
5 him to join the University of Nevada at Reno and that
6 will go to strengthen our program.
7 We continue to have strong diversion
8 committees in both the north and the south. I'm
9 particularly pleased with the southern committee which I
10 have just recently revamped which includes members from
11 the old medical society committees when they were run.
12 And there is some valuable experience there, but also
13 from the individual hospital and also from the, you
14 know, current diversion program. So I think it's
15 bridging committees down there.
16 Doctors Coughlin and Belcourt continue to run
17 a very tightly run diversion committee in the north. At
18 this time I think I have run out of things to say.
19 And I would like to introduce Tim Coughlin who
20 I would like to have him say a few words about the
21 north.
22 DR. COUGHLIN: I'm Dr. Coughlin. The north
23 seems to be --
24 PRESIDENT HUG-ENGLISH: Come up to the table.
25 Sorry. We are a little packed in here today.
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1 DR. COUGHLIN: Thank you for having us today.
2 I want to thank Brad for the great job he has done here.
3 The north seems to be fairly stable right now.
4 We have a very active caduceus committee which is sort
5 of an AA meeting for doctors.
6 We have added John Chappel to the diversion
7 committee in the north which I'm sure you all know, and
8 I think he will be a great asset to us.
9 We are looking forward to working with
10 Dr. Manski. He is a very impressive guy, and I think we
11 are ready to take this to another level that we haven't
12 had before.
13 Thank you.
14 DR. THOMPSON: At this time I would like to
15 introduce Dr. Manski.
16 DR. MANSKI: Thank you, Brad. I want to thank
17 the board for allowing me to address you at this time.
18 I'm really looking forward to coming here and
19 working with the program. As an officer of the
20 Federation of State Physicians Health Programs, I have
21 been watching this program grow. And I think it's --
22 watched it grow to the stage where it's ready to gel.
23 It's a privilege working with a strong board
24 here and with the diversion committees. And I think by
25 using out reach and education we can identify physicians
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25
1 with illnesses much earlier in the stage of their
2 illness that's long before they have done any patient
3 harm. We can get them into treatment. We can move very
4 quickly because we are operating on health orientation
5 so that we can contact the physician.
6 There are a number of people, I understand,
7 who are very good at confrontation and good at being
8 able to convince people to join our program. And if we
9 can get them in early and get them treated, I think we
10 cannot only perform a service to the individual
11 physicians but to the community as a whole.
12 And, again, thank you so much for allowing me
13 this privilege.
14 PRESIDENT HUG-ENGLISH: Great.
15 DR. THOMPSON: Thank you, Peter. At this time
16 I still can't figure out why he is coming here, but I
17 guess we stepped outside and in terms of the weather New
18 York must get old after a while.
19 At this time I would like to open for
20 questions anybody may have. And everything I have
21 presented I have copies if anybody wishes.
22 DR. MONTOYA: Dr. Manski, Steve Montoya. Do
23 you have an overall vision of what you want to encompass
24 in this new endeavor you have here in Nevada? Do you
25 have a model based upon your reasons in New York or are
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1 you going to be making something new?
2 DR. MANSKI: Right. I think the model of the
3 program has to be adjusted to the individual community,
4 individual state. But my vision would be to help the
5 program to grow, to grow in stature, to perhaps grow in
6 numbers, to grow in efficiency, to increase the
7 educational and out reach activities so that we can
8 intervene more quickly in the program, to work with a
9 very active board, to also promote fund-raising so that
10 we can eventually get an office and maybe an office
11 staff so we can operate more efficiently.
12 DR. MONTOYA: Thank you.
13 PRESIDENT HUG-ENGLISH: Any other questions
14 from any board members? I certainly think if --
15 DR. ROSENCRANTZ: Just a comment because I was
16 here in December, and I know that the board really
17 questioned where we stood. I think this foundation has
18 taken a real active role since Dr. Rueckl and Carol
19 aren't on board.
20 The people in the north and the people in the
21 south who serve on the foundation board have been very
22 active.
23 We conducted three face-to-face interviews
24 with bringing people in. We really worked hard.
25 We have had several different board meetings,
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1 and we are going to continue to work with Dr. Manski and
2 make this the best program in America. With Dr. Manski
3 on boarding we can do that.
4 I want you to know we have really come a long
5 way, and I appreciate the fact that you gave us the time
6 to hire Mr. Manski. Thank you very much.
7 PRESIDENT HUG-ENGLISH: Well, I think this
8 board recognizes and appreciates all the work that this
9 diversion program has done up to now. I certainly
10 appreciate you stepping in in a very tough time and
11 bringing it forward.
12 I appreciate Dr. Coughlin, Dr. Belcourt and
13 everyone else's involvement in such an important
14 program.
15 I think that this board has supported the
16 diversion program and will continue to support the
17 diversion program. We feel it's extremely important.
18 We are thrilled you have been able to move
19 forward so quickly and have brought Dr. Manski here.
20 That's very exciting, and we look forward to working
21 with you.
22 Thank you all for coming. Dr. Belcourt, did
23 you have something you wanted to say to us?
24 DR. BELCOURT: I think we have one of the
25 highest caliber directors in the country that has just
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28
1 arrived here in Nevada.
2 And, you know, truthfully if the program is
3 going to stay at its current stature, we can't afford
4 him. So we really want to see this program expand to
5 get the people that we need to be getting into the
6 program and to enhance our relationships with medical
7 staffs particularly some of which have been not as good
8 as they could have been in the past.
9 So that's the growing in stature that we are
10 looking at. And this will be --
11 We have put some other programs in place that
12 we'll tell you all about at a later date for monitoring
13 that we think will be state of the art as far as
14 nationwide is concerned. So it looks like a very
15 exciting time for our committee.
16 PRESIDENT HUG-ENGLISH: It certainly sounds
17 like it. And, again, I thank all of you for coming.
18 And we welcome you, Dr. Manski, and look
19 forward to working with you in the future. Thank you.
20 Just continue then with agenda item number 15,
21 and do we have our physicians assistant?
22 MR. LANZILLOTTA: Down here. Good morning.
23 Can you hear me?
24 PRESIDENT HUG-ENGLISH: Yes, we can.
25 MR. LANZILLOTTA: More physician assistants
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1 are working the situations involving end-of-life care
2 and Hospice. The death of a patient in these
3 circumstances is often unpredictable and can be
4 complicated for the caretakers and the family.
5 At times it's difficult for the physician to
6 be on premises to pronounce death. But delay of
7 pronouncement of death can be trying and problematic for
8 the facility providing care.
9 Chapter 440, 415 of the NRS permits
10 pronouncement of death by a registered nurse if
11 authorized by the patient's physician.
12 Physicians assistants as delegates of their
13 providing physician are able to diagnose, treat and are
14 often involved in these particular patients as advocates
15 and end-of-life care.
16 However, they are not legally able to
17 pronounce patients. It would spare the physician, the
18 family, if a PA can pronounce particularly in cases
19 where death is anticipated.
20 We are requesting and appreciate the board's
21 opinion and advice on the procedure to change this
22 chapter of the NRS adding physician assistants to
23 registered nurses as authorized agents of the
24 supervising physician to pronounce a patient dead.
25 PRESIDENT HUG-ENGLISH: John, thank you. I
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1 guess at this time I would open it up for discussion
2 from board members and certainly from maybe our legal
3 counsel as well.
4 MR. LEGARZA: John and I have talked about
5 this in the past. Obviously the next session of the
6 legislature is going to start January 2005, February
7 2005, something like that. Any legislative package that
8 you may have -- and I know that you will be working on
9 it later -- just some questions for legislation that you
10 may propose in the next session.
11 If the board is of the opinion that this is
12 something that the board thinks that PAs ought to be
13 able to do, certainly the board could get an ADR from
14 one member of the legislature to hopefully submit this
15 for consideration to change the statute to allow PAs to
16 pronounce.
17 They can't at the present time. And I don't
18 know why they can't. They don't have that authority.
19 DR. MONTOYA: Steve Montoya talking. Did this
20 come from one of your PA meetings or was it a committee?
21 I'm trying to get a grip of how big of a problem it
22 actually is.
23 MR. LANZILLOTTA: Actually, Dr. Montoya, it
24 came from one PA in particular who works with other PAs
25 that are involved in Hospice and doing nursing home
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1 rounds and care.
2 And they were particularly -- It came up
3 because the situation would arise where the -- under the
4 supervising physician they would be following a patient
5 and the patient's death, of course, would come at a time
6 when the physician may not be reached, the family --
7 there is a lot of interaction there where it becomes
8 somewhat a problem and would be better facilitated if a
9 PA that would normally be making rounds or following
10 this patient could be there to pronounce the patient.
11 But it came primarily from PAs working in the
12 field, working in that area.
13 MR. LESSLY: Madam President, the June meeting
14 of the board we will be submitting a package for
15 legislation, and I will suggest that you refer this to
16 Mr. Legarza for inclusion in that package for your
17 informal consideration and decision in the June meeting.
18 PRESIDENT HUG-ENGLISH: Thank you. I guess I
19 have one other question, John. Have you looked at what
20 other states are doing for -- with this requirement for
21 PAs? Is this something that is sort of routine in the
22 scope of PA practice?
23 MR. LANZILLOTTA: In the model legislation, it
24 is written up as that. And it's been really state by
25 state as far as the decision on whether PAs are able to
PEGGY HOOGS & ASSOCIATES (775) 327-4460
32
1 do this in the state legislature. And I can't give you
2 a number of states that actually are -- where it is in
3 their legislation, and I would say it's mixed.
4 I mean, there are some states where obviously
5 it is not. And Nevada is one of them right now.
6 But it's gone state by state. And it's
7 probably one of those situations where I would say that
8 just now it's come up. I think just with the
9 generalized increase in Hospices, nursing homes, and so
10 on and PAs are working more in those areas that this has
11 come up and not previously.
12 PRESIDENT HUG-ENGLISH: Thank you.
13 MR. KINGSLEY: Dr. Hug-English?
14 PRESIDENT HUG-ENGLISH: Yes.
15 MR. KINGSLEY: This is Ed Kingsley down here
16 in the south.
17 PRESIDENT HUG-ENGLISH: Hi, Ed.
18 MR. KINGSLEY: Hi. I want to make -- first of
19 all, I'm not against a change in legislation allowing
20 PAs to pronounce death. But as a board member of the
21 Nathen Allen Hospice which is the largest nonprofit
22 Hospice in the state and active participant in Hospice
23 activities in the last 20 years, I have never been aware
24 there has been a problem with pronouncing the patients
25 by the nurses whether they are in nursing homes or at
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1 home.
2 Patients when they die are routinely
3 pronounced by these nurses who have been delegated that
4 authority by the attending physician. And this is the
5 first I have heard there may be a potential problem with
6 that set up the way it has been going.
7 As far as I know it has been doing well, but
8 perhaps that's not the case.
9 PRESIDENT HUG-ENGLISH: Thank you. Dr. Anwar?
10 DR. ANWAR: Javaid Anwar. My only comment is
11 that in care involving a patient where nurses are
12 supposed to carry out orders of physicians as well as
13 PAs, we have a law that allows nurses who do not write
14 orders for the patients that have been given orders by a
15 physician they are able to evaluate the patients that
16 are alive or dead and pronounced the patient dead by the
17 RN.
18 However, a PA who works second to or under the
19 supervision of a physician and is able to give orders to
20 RN is not able to do that, I think, is ridiculous from
21 that point of view.
22 So I support strongly that there is no reason
23 why a PA should not be able to pronounce death in
24 addition to the RN.
25 PRESIDENT HUG-ENGLISH: Thank you.
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1 DR. LUBRITZ: I agree with Dr. Anwar. And I
2 would only second what he says. I can't add anything.
3 I think he said it very well.
4 It seems inappropriate that they should not be
5 able to do that specific task when they do work with the
6 physician and essentially do give orders to nurses.
7 PRESIDENT HUG-ENGLISH: Is there any board
8 member that has an objection to this proposal? Okay.
9 If not I think we will instruct our legal team
10 to move forward and include that for our June meeting
11 when we come forward with a legislative packet. So we
12 will work on that.
13 And, John, I appreciate you bringing that to
14 our attention.
15 MR. LANZILLOTTA: Thank you very much.
16 PRESIDENT HUG-ENGLISH: Did you have anything
17 else in your report to add?
18 MR. LANZILLOTTA: No.
19 PRESIDENT HUG-ENGLISH: Okay. Thank you.
20 Then our respiratory care advisory committee
21 member, Mike Garcia.
22 MR. GARCIA: I don't have anything quite as
23 exciting as that.
24 I will tell you I was the director of a
25 Hospice, three of them, in New Mexico for several years.
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35
1 And the one thing I can assure you at the moment of
2 death in the patient's home or the nursing home,
3 wherever the case may be, because a Hospice is not a
4 place, it's a concept, anything that delays that
5 pronouncing of death in certain states -- as I remember
6 in New Mexico, can have that patient grabbed and moved
7 to a hospital, can disrupt that entire goal of having
8 the patient die with family, friends, et cetera, at the
9 bedside.
10 So as a Hospice appreciator, I would certainly
11 encourage the board to support that even if it helps two
12 or three families a year in the state Nevada it's
13 worthwhile.
14 As far as the respiratory reports are
15 concerned, we do have a couple of things going one.
16 One thing I spoke with Counselor Lessly this
17 morning. Respiratory advisory committee will be
18 requesting that the board consider language -- and
19 Counselor Legarza has said wherein we can have the NRS
20 revised to reflect that respiratory therapists do not
21 require a separate license in the state of Nevada to
22 draw arterial blood gases.
23 That license has been in effect, I believe,
24 since the 1950s in this state. But when we license
25 respiratory therapists under this board, it is a part of
PEGGY HOOGS & ASSOCIATES (775) 327-4460
36
1 the scope of their practice. And currently our
2 practitioners are presently having to pay for both
3 licenses. So we are going to request in June to make
4 the Department of Health license go away or be revised
5 to some extent.
6 And, secondly, we are receiving concerns from
7 your practitioners particularly in the rural communities
8 relating to in-home life support systems and who is
9 qualified to care for patients in the home on
10 respirators.
11 It has come to our attention that some in-home
12 medical equipment companies are hiring emergency medical
13 technicians and utilizing them to provide that care in
14 lieu of a respiratory therapist or a physician which, as
15 we understand it, are the two people qualified in the
16 state of Nevada to provide that sort of service.
17 Just so you are aware -- so the board is
18 aware, we are approaching the Department of Health to
19 question as to whether or not an EMT in the state of
20 Nevada not acting in pre-hospital care but acting on
21 their own as an independent agent of an employee of a
22 proprietory organization can provide in-home respiratory
23 care.
24 We know that their academic curriculum does
25 not prepare them for that nor are the other training
PEGGY HOOGS & ASSOCIATES (775) 327-4460
37
1 programs to do so after they graduate.
2 And as much as we certainly are supportive of
3 the pre-hospital care that EMTs provide, we believe that
4 there is a role for respiratory therapists in the state
5 of Nevada and a role for EMTs. And in this case the two
6 shouldn't blend.
7 So when we get a response from the Department
8 of Health we will report that to the board.
9 Otherwise, we have one question and that's
10 related to a renewals of licensure. And we were just
11 wondering how that was going for the respiratory
12 practitioners.
13 We are certainly not hearing anything in the
14 community sounding like there has been any major
15 difficulties. In fact, it sounds like it has gone
16 extremely smoothly, but then I'm not up here so I don't
17 see the hustles and bustles that others might. So if
18 the board can respond to us on that.
19 MR. LESSLY: I can respond to you. Lynnette
20 is not here. But I think there were 140 respiratory
21 therapists who were suspended. A couple of them have
22 been reinstated. We don't know if those people are
23 intending to work in the state of Nevada.
24 MR. GARCIA: Now 140 that makes me nervous.
25 There are 900 out there, and there is probably 100 that
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38
1 are traveling therapists. I am hoping of the 100 of the
2 140 are travelers.
3 MR. LESSLY: And not practicing.
4 MR. GARCIA: And not practicing. I will get
5 that word out. Our society meeting is tomorrow, and I
6 will broadcast that to the managers at that meeting.
7 Although, I know in the south lists were done on every
8 human resources checked in every hospital.
9 MR. LESSLY: And the hospitals are checking
10 with us.
11 MR. GARCIA: That's all. Unless there are
12 questions from the board.
13 PRESIDENT HUG-ENGLISH: Thank you, Mike.
14 Anybody have any questions? I would just like
15 to say the issue of putting that forward as a DBR I
16 don't think that's going to be a problem. I think
17 probably what happened was that license or blood gases
18 proceeded the licensure of respiratory therapists. And
19 now that we are doing that that is really redundant.
20 MR. GARCIA: We believe so.
21 PRESIDENT HUG-ENGLISH: So we can probably
22 move forward to do that.
23 MR. LEGARZA: We have tried informally too
24 with them to try and get them to back off of that
25 licensing requirement and they fought us because it's
PEGGY HOOGS & ASSOCIATES (775) 327-4460
39
1 $50?
2 MR. GARCIA: I think it's supposed to have
3 gone up to 75.
4 MR. LEGARZA: That's a year. And that was
5 revenue to them so they didn't want to back off on.
6 And with your permission I will work on that
7 as part of the legislative package for you to consider
8 in June if that's okay.
9 MR. GARCIA: And a compromise might be a point
10 of service like they do for RNs where they pay a lower
11 fee.
12 MR. LEGARZA: At least you and I can represent
13 they wouldn't work with us informally, is that true?
14 MR. GARCIA: That's for sure.
15 PRESIDENT HUG-ENGLISH: If I'm not hearing any
16 objection to that, we will add that also to the work for
17 our legal team to draft for us in June.
18 Investigative committee reports? Are we ready
19 for those or do we want to do those later?
20 DR. BAEPLER: I don't know if the printouts
21 are ready for distribution or not. I haven't seen them.
22 They are not done yet.
23 PRESIDENT HUG-ENGLISH: We will do that later
24 today.
25 Don, you want to give us the secretary
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40
1 treasurer report?
2 DR. BAEPLER: Sure. Although it's in your
3 handout, two sheets. One is the balance sheet which
4 essentially shows the assets and liabilities that --
5 MR. KINGSLEY: Excuse us. We can't hear down
6 here.
7 DR. BAEPLER: Sorry about that. For the
8 treasurer's report we have two sheets. One is the
9 balance sheet that shows that the assets and liabilities
10 are in balance.
11 The more important sheet is the second one
12 which is the profit and loss budget versus actual. It
13 pretty much tells you that some revenues are coming in
14 above our expectations. Others are a little bit below
15 the expectations.
16 There is nothing in this which is off of our
17 original projected figures. We are in very good shape
18 in terms of what we had projected.
19 I know their equipment and computer system
20 there is enough money still left in that budget item to
21 accommodate the requests that we discussed with
22 reference to upgrading the computer equipment for
23 example.
24 Looks like we will finish out this fiscal year
25 in good shape.
PEGGY HOOGS & ASSOCIATES (775) 327-4460
41
1 DR. KINGSLEY: Question. This is Dr. Kingsley
2 down south.
3 Dr. Baepler, on that page two, under expenses,
4 number four, operating. Under the audit, we notice that
5 the amount listed is $51,000.
6 DR. BAEPLER: Right.
7 MR. KINGSLEY: It was our understanding that
8 the federation -- actually, their bid was $28,000. Was
9 there additional costs in there that accounted for that?
10 MR. BAEPLER: There are two --
11 MR. LESSLY: There are two audits conducted of
12 this board. One is conducted by a CPA firm required by
13 statute.
14 DR. BAEPLER: One was a performance audit.
15 One was a financial fiscal audit.
16 DR. KINGSLEY: All right. Thank you.
17 DR. ANWAR: And as a lay person, I have never
18 been able to understand how do assets and liabilities
19 all of this match up to the last cent?
20 DR. BAEPLER: It's an art form that only CPAs
21 can arrive at.
22 I candidly use the term that, not just with
23 this board but with any entity, these figures are
24 somewhat forced. Usually presented in a way that they
25 are unintelligible to non-CPAs.
PEGGY HOOGS & ASSOCIATES (775) 327-4460
42
1 PRESIDENT HUG-ENGLISH: Any other comments
2 about the balance sheet that was distributed? Any
3 further discussion? If not, I will set the motion to
4 approve this as stated.
5 DR. MONTOYA: So moved.
6 PRESIDENT HUG-ENGLISH: All in favor?
7 THE BOARD: Aye.
8 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
9 in favor and this is approved.
10 Okay. I think we will jump back then to
11 agenda item number four. And this is consideration of
12 adoption of proposed amendments to the NACs. And we
13 have the --
14 Dr. Baepler had chaired this committee. And I
15 just want to make a couple of introductory comments. I
16 don't know. Are people in the audience here to comment
17 on this particular regulation? How many of you are here
18 for that today? Just one.
19 How many are here in Vegas to comment on the
20 proposed change to the regulation?
21 DR. KINGSLEY: There are a few down here that
22 would like to comment.
23 PRESIDENT HUG-ENGLISH: Okay. I just want to
24 have a couple of introductory statements and that is to
25 say that Dr. Baepler has chaired the committee on
PEGGY HOOGS & ASSOCIATES (775) 327-4460
43
1 continued physicians' competency.
2 And I thank he and the other committee members
3 for being willing to be part of this. This has been an
4 issue that has come forward on a national level a couple
5 of years ago in the federation.
6 It's an issue that we felt was important to
7 look at. We formed a committee to do so. And the
8 committee has done a lot of work and research on it. We
9 have held now two sets of workshops, two in Reno, two in
10 Las Vegas, to get public comments. And I certainly
11 appreciate all of those people that have been willing to
12 come forward and give us feedback on these proposed
13 regulations.
14 I think that we have and the board has all
15 received really a full binder full of comments -- public
16 comments as well as a very thorough and complete
17 introduction by Dr. Baepler. I really don't want to
18 spend a lot of time duplicating what has already been
19 stated and what has already been introduced for public
20 record.
21 So this morning what I would really like to
22 address is to hear any additional comments that are
23 different than what has already been presented to the
24 board and then to allow the board to discuss these
25 regulations.
PEGGY HOOGS & ASSOCIATES (775) 327-4460
44
1 So I guess -- I don't know who is down there,
2 but I guess I would start and ask if there is anyone
3 here who would like to address the board on this topic.
4 Please come forward.
5 I'm sorry. We have someone that has come
6 forward in Reno and then as soon as that is completed we
7 will send it down your way.
8 DR. ZIMIT: Thank you. Excuse me. My name is
9 Dr. Zimit (phonetic). I have been a practicing
10 physician in the state of Nevada for approximately, I
11 think, the last 34 years.
12 I'm not really sure why we are doing this
13 again. And, as you stated, we went through this one
14 year ago. And at that time, as I recall, the Nevada
15 State Medical Association, the head of the rural
16 clinics, the medical school, the public health
17 department, and almost every physician in the medical
18 organization in the state of Nevada were unanimously
19 against these proposed changes. And this is all a
20 matter of public record.
21 I felt that the recent modification to your
22 proposed changes were negligible. Hundreds and hundreds
23 of our clinic patients have phoned or sent letters of
24 opposition voicing their opposition of the changes.
25 I have brought stacks with me. You already
PEGGY HOOGS & ASSOCIATES (775) 327-4460
45
1 have them. If you need it again, I will be more than
2 happy to supply you with those letters.
3 You stated that the purpose of this regulation
4 is to protect the public by establishing some
5 requirement that physicians who have already been
6 licensed and are authorized to practice medicine in the
7 state of Nevada provide the Nevada State Board of
8 Medical Examiners with some demonstration of their
9 proficiency to continue to practice medicine in this
10 state.
11 I don't understand how this would protect the
12 public. There are physicians in this state who have no
13 malpractice suits and yet who take no so-called
14 proficiency exams. There are many physicians who always
15 have taken proficiency exams and who have had lawsuits.
16 And so how does this protect the public? I don't
17 understand what you are truly trying to solve here.
18 Giving physicians tests are not going to stop
19 lawsuits or lower malpractice.
20 I feel that this is really a waste of time,
21 energy, and money.
22 I feel that the public really and maybe the
23 legislature fully doesn't understand the real problem.
24 One of the greatest values that I ever found
25 in this state was the value of that screening panel.
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46
1 And I would strongly recommend, if you can, reestablish
2 the screening panel and desist in giving examinations to
3 physicians that have none or few malpractice suits.
4 There are only a few doctors in this state who
5 have created the problem. I feel if we dealt with them,
6 the problem would resolve.
7 You know, my day when there was a malpractice
8 suit, too many years ago to mention, if a surgeon came
9 into an operating room and took off the wrong leg and he
10 was drunk, that was malpractice.
11 Today the reasons for malpractice is really
12 just an opportunity for some people to seize some easy
13 money, in my opinion. And, unfortunately, I feel it's
14 encouraged by our society in the legal system.
15 All physicians have to fulfill the continuing
16 medical requirements yearly so everyone keeps abreast of
17 what is required.
18 Every doctor in this state could therefore
19 pass any legitimate proficiency exam. But how do you
20 test a doctor that has limited his practice to do what
21 he wishes to do? For example, a homeopathic physician,
22 one doing research, one writing a book, one teaching at
23 the medical school?
24 I don't feel Nevada can afford to get rid of
25 more good doctors. We don't have enough already.
PEGGY HOOGS & ASSOCIATES (775) 327-4460
47
1 Should you be the only medical board in the
2 nation to pass such a requirement against the wishes of
3 the entire medical profession, this will obviously end
4 up in the court system. Who wins then? And it's surely
5 not the people of this state.
6 Also, I notice that you added an out clause to
7 your proposed regulation. It states that the board's
8 discretion quote, unquote, you can get around the
9 specific required exam. I think this will automatically
10 open the board to great criticism and accusations to
11 favoritism.
12 In conclusion, a Nevada senator wrote, Thank
13 you so much for faxing to me your letter to the Nevada
14 State Board of Examiners regarding Chapter 630 of the
15 Nevada Administrative Code.
16 I agree with you that this action would harm
17 our medical communities, and we are in the process of
18 requesting that the board withdraw this regulation.
19 Please feel free to call or write my office
20 any time I can be of help to you. Randolph J.
21 Townsend, State of Nevada Senator.
22 PRESIDENT HUG-ENGLISH: Thank you, Dr. Zimit
23 (phonetic).
24 Anybody else up here in Reno to speak on this?
25 Okay.
PEGGY HOOGS & ASSOCIATES (775) 327-4460
48
1 We'll send it down to Las Vegas if there were
2 comments.
3 DR. KINGSLEY: We're speaking on behalf of one
4 of our society's members, Dr. Joe Hardy who I think most
5 of you know is an assemblyman down here and a family
6 practitioner who was unable to make the meeting this
7 morning but did ask that a question be raised that I
8 don't think has been raised in previous workshops.
9 It concerns -- specifically, his concern is
10 how this proposed regulation would affect family
11 practitioners urban and rural. And, specifically,
12 apparently the American Academy of Family Practitioners
13 requires certification every six years, an examination.
14 And from the notes that he has provided me, it
15 would appear that although that is considered a quote
16 formal examination that could, I guess, be approved by
17 the board, I don't think that it's validated pursuant to
18 provisions of the standards for educational and
19 psychological testing.
20 At least, he had question about that. And I
21 don't know if anyone is able to address that specific
22 question. That was his concern.
23 DR. BAEPLER: It would be the intent of the
24 committee that that would qualify. And, you know, we
25 have to work out a little manual if these regulations
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1 pass, that would kind of spell out the appeal processes,
2 for example, in case a person opts to take a pure review
3 and doesn't make it, there has to be an appellate
4 process. And we have to be a little more explicit on
5 this exception because the rural hospitals, for example,
6 are not typically Jaco accredited.
7 But we have to make an exception there because
8 they are accredited by other organizations that have
9 decent standards.
10 So we have to, like I say, work out a manual
11 to specify procedures and appellate provisions. And in
12 this instance, I'm sure that that test would be quite
13 adequate.
14 PRESIDENT HUG-ENGLISH: Any other comments
15 from Vegas?
16 DR. BUNCH: Yes. This is Dr. Don Bunch in Las
17 Vegas, and I have practiced in Las Vegas in
18 cardiovascular surgery since 1973.
19 And I'm addressing this group just off the
20 cuff. I do not have prepared testimony but would like
21 to bring to the board's attention something that may not
22 have been covered in previous workshops. Alternatively
23 they may have.
24 But the proposed regulations that you have
25 before you totally and completely ignore a very
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1 important and growing group of physicians. And that is
2 the retired, non-practicing, non-insured physician.
3 There are no -- there is no language in the regulations
4 to cover that group of physicians.
5 I hold a license, and I keep up my CMEs. And
6 to me -- That license hangs on the wall, and every time
7 I walk in my office and look at that license, I look
8 upon it with pride. Occasionally I'm reminded of the
9 many, many years of service that I have given
10 unselfishly to this community.
11 Now the board wishes to take this license away
12 from me. The fact that the license is active, even
13 though I do not practice, is a source of pride for me,
14 as I mentioned. It defines me and is part of my self
15 esteem on a personal factor to have and be licensed.
16 There was a time that I was a pilot. I flew
17 an airplane and, of course, I no longer do that. I did
18 not keep current and my license was taken away. The
19 pilot's license was therefore decertified and revoked,
20 and I am now an ex-pilot. I strongly do not wish to be
21 an ex-doctor.
22 PRESIDENT HUG-ENGLISH: Thank you, Dr. Bunch.
23 Any further comments?
24 I have a couple of comments that I would like
25 to make to the board members.
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1 And I appreciate the public comments that we
2 have had today.
3 Again, I want to thank the committee for their
4 hard work on this very complex and very complicated
5 issue.
6 I think that we are at a time in our state
7 where we have one of the lowest numbers of physicians
8 per capita. Right now we are the only state in the
9 nation that requires a three-year post-graduate-training
10 program. If we were to pass this competency regulation,
11 we would also be the only state in the nation to have
12 such a requirement.
13 And I think at this particular time that we
14 need to be careful that we don't put up any other
15 barriers that would be seen as potentially obstructive
16 to new physicians coming into this state.
17 Secondly, I think that we have been told in
18 the past that there is a legislative intent about this
19 issue. I can speak for my experience in the last
20 legislative session that I did not find this to be the
21 case at all.
22 I sat before Senator Townsend's committee at
23 which time he indicated that they did not want this
24 board to pursue this kind of regulation. In addition, I
25 was told by the governor's staff that they do not have
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1 any desire for us to pursue this regulation.
2 I think that all of the public hearings that
3 we have had have shown a lot of very valid concerns that
4 the public has presented about how this would impact
5 certain sub-specialties within the state.
6 I also feel that within a couple of years
7 most, if not all, of the specialties will require some
8 sort of recertification, and that this in large part
9 will satisfy what this regulation attempts to do.
10 I also feel that many of the issues -- that
11 most of the issues that have been brought before this
12 board would not be changed in any way based on this
13 regulation. There have been very few. I can think of
14 maybe two in eight years of serving on the board that
15 have been issues of competency that have come before the
16 board that would be changed by this regulation.
17 I personally feel we as a board need to be
18 very watchful and patient to see what other states are
19 doing in this matter and what is developing nationally
20 before we take action. I think it's premature for us to
21 do it at this time.
22 We are also going to be facing three new board
23 members coming on this summer. And I think it's
24 important that this board grows and develops and they
25 have a chance to look at this issue in detail.
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1 And my recommendation would be that we as a
2 board acknowledge the work that this committee has done,
3 acknowledge that this proposal is a very good working
4 document, but I would really personally like to see us
5 table it indefinitely until such time as the legislature
6 indicates to us that they feel it's important that we go
7 forward with.
8 So those are my comments and my thoughts. And
9 now I would open it up to the board for discussion.
10 DR. MONTOYA: Steve Montoya speaking here. I
11 was part of the committee that helped put this together.
12 And I have to say it's a good, rough, well thought out
13 document and it started out with good intentions. But
14 we all know the road to hell was paved by good
15 intentions.
16 It's still a document in evolution. As
17 Dr. Bunch certainly pointed out retirees certainly have
18 to be included in this.
19 I get around to three hospitals, especially
20 there in Las Vegas, quite a bit. And people are
21 stopping me in the halls quite frequently asking me what
22 the hell were we talking about with this new competency
23 thing.
24 Turns out a lot of them didn't read the thing.
25 They read the first sentence that said they have to
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1 demonstrate competency, and it scared a lot of people.
2 They said it's just another hurdle Nevada is putting in
3 my way.
4 It's bad enough I will have to worry about my
5 tripling malpractice insurance. I'm an obstetrician and
6 it's a fact. We have been damaged by our own success in
7 certain areas.
8 We have a very strict initial licensure
9 requirement. We have an active board that looks into
10 all malpractice cases.
11 We are getting better communications with the
12 hospitals that are -- from which these malpractice cases
13 arise. Not all. It's not an all encompassing. We are
14 getting better communication, and I think that will take
15 care of a lot of our problems.
16 Also this seems to discourage doctors wanting
17 to come into the state.
18 And speaking with the Filipino contingents
19 that we had at the last meeting and afterwards in the
20 halls, a lot of Filipino doctors at their meetings have
21 felt that there is an act of discouragement of doctors
22 coming into the state.
23 The boards, national boards, the national
24 specialty boards of OB-GYN, I have to recertify every 10
25 years to maintain my board certification. I do
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1 recertify every year. And there is more certification
2 coming on board for maybe more frequent and harder
3 recertifications.
4 I would have to say the time is not right for
5 this document. I would prefer this document be held in
6 abeyance. And if it ever came to the forefront and
7 where we actually needed a document, I think this thing
8 ought to be refined. This should be held in abeyance
9 and brought forward if a need should come eventually.
10 I realize I have had to change my mind on
11 this. And it's been a long, hard decision, I have to
12 say, sitting at those meetings and even when I'm
13 speaking in the halls with these doctors who have come
14 out with support of this document which I think is going
15 to be very valuable, but I think right now it's
16 premature.
17 PRESIDENT HUG-ENGLISH: Thank you.
18 DR. BAEPLER: This is one of those situations
19 where I think reasonable people looking at the same set
20 of circumstances are going to agree to disagree.
21 And I don't want to belabor the point, but if
22 you look at NRS 630.003, it's very clear what the
23 position of the legislature is on this particular item.
24 It says for the protection and benefit of the
25 public the legislature delegates to the board of medical
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1 examiners the power and the duty to determine the
2 initial and continuing competence of physicians.
3 It says the board must exercise its regulatory
4 power to ensure that the interest of the medical
5 professional do not outweigh the interest of the public.
6 A way of saying that this medical board like
7 all medical boards represents the public and not the
8 medical society. However, doesn't mean that there is an
9 adversarial position between the two.
10 As I said before, one of the best ways that we
11 can serve the public is to make Nevada a doctor-friendly
12 state where we can attract and keep good doctors while
13 exercising our licensing authority and our disciplinary
14 authority.
15 This represents a document with tremendous
16 input from the medical groups. All of the letters and
17 documents that you refer to has resulted in a total
18 change in the thinking of this board or the committee
19 from an original universal examination for everyone, you
20 know, the easy answer to a system now where no one would
21 have to take an exam.
22 As a recommendation from the medical groups,
23 we have arrived at a system that will not inconvenience
24 in any way the vast majority of doctors practicing
25 medicine in this state.
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1 It's starting -- similar to starting something
2 at a level to evaluate it after 2007. And if it does
3 not meet our objectives, to tweak it upward a little bit
4 for 2017.
5 There is a national movement on to come up
6 with competency, we call ours proficiency, but
7 competency testing. You have a handout from the
8 Citizens Advocacy Center. They detail why they don't
9 want our proposal passed. Because they want to advocate
10 at the national level through federal legislation
11 something which is much more rigorous, quite frankly.
12 My feeling, again, is that if the states are
13 not proactive in starting to tackle this, then other
14 groups will step in. And once again the medical
15 profession will be in the position of reactive rather
16 than coactive.
17 I know there is interest at the federal level
18 in doing this as well as private organizations. This
19 Citizens Advocacy Center, I believe, is the out reach of
20 the Ralph Nader organization. So it's a well-organized
21 group.
22 PRESIDENT HUG-ENGLISH: Dr. Titus?
23 DR. TITUS: I have struggled with this issue
24 since I became a member of this board, and initially
25 when I first sat on the board was vehemently opposed to
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1 the proposed regulations or even the idea of passing yet
2 another rule that we would have to follow.
3 However, I have changed fairly dramatically my
4 views with education and learning and listening and
5 reading.
6 I now sit on a national committee regarding
7 this issue and have a strong proponent of regulations
8 that force physicians to maintain a level of competency.
9 I, however, am also equally opposed to the
10 regulation that we are proposing and would be actually
11 against this regulation not for the reasons that some of
12 my peers have said but for the reason that it is very --
13 we have tried to please so many people with these regs
14 and we have tried to avoid having to be tested or put on
15 the line, that we have diluted this thing so it really
16 holds no weight whatsoever. And I do not believe that
17 this particular regulation in any way if we pass it
18 would guarantee any level of competency. I think it has
19 been totally diluted.
20 The standard I feel we need to look at -- the
21 bar has been set by the American Board of Family
22 Practice. The American Board of Family Practice looked
23 at this issue recognizing it as a national problem, a
24 national issue.
25 Many states are looking at it. All the boards
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1 are now looking at it. Various professional
2 organizations are looking at it.
3 The American Board of Family Practice has now
4 established a program to ensure that its members remain
5 competent throughout our practice.
6 There is a term out there called life-long
7 learning that we as physicians and any professional
8 organization, I think, would want to hold to that. We
9 do not want to be incompetent as we get older.
10 I have been a doc now in my little community
11 for 20 years and it scares me greatly that I'm
12 potentially behind in the times. And I work very hard
13 not getting there. And to the credit of American
14 Academy of Family Practice and American Board of Family
15 Practice they have installed this thinking in our
16 programs right from the start that we need to work very
17 hard to maintain our competency.
18 I'm also a pilot, a current pilot. And I
19 think as a current pilot every two years we have to
20 review how competent we are. We don't want to be flying
21 if we are not competent nor do we want to be doctors if
22 we are not competent.
23 So I think the profession is and will have to
24 be in favor of this. We have to maintain a certain
25 level for the citizens of this state.
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1 Dr. Baepler and the rest of members of the
2 committee have worked very, very hard on this particular
3 legislation. They have tried to encompass the rural
4 areas. They have tried to encompass the various
5 professional organization and various specialties. But,
6 unfortunately, I really feel that this is not the right
7 piece.
8 I would put out that we table this right now.
9 Let some of the work be done on a national level with
10 the various professional organizations, and I think our
11 state can still be in the forefront.
12 I won't be a member of this board in the next
13 several months, but I will stay on the national
14 committee that I'm on.
15 And I think we need to keep working and
16 looking forward, but I don't think we fail if we don't
17 pass this piece. But I think there is more work to be
18 done. And I know there isn't a lot of energy, but I
19 can't support what we have on the table.
20 PRESIDENT HUG-ENGLISH: Thank you. Was that a
21 motion to table?
22 DR. TITUS: I am not so sure we are -- I
23 didn't -- that would be my opinion, and I will wait for
24 other discussion.
25 PRESIDENT HUG-ENGLISH: Other further
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1 discussion?
2 Dr. Jones.
3 DR. JONES: I would just like to ditto what
4 was just said and also what Dr. Hug and Dr. Montoya
5 said. And I can't say it any better. So I will just
6 ditto the sentiments from those three people.
7 PRESIDENT HUG-ENGLISH: Dr. Anwar?
8 DR. ANWAR: Thank you. I want to make some
9 broader comments on what has been shown as what the
10 legislature's intent is regarding this board.
11 And my opinion is after a lot of thinking and
12 discussion with our colleagues and peers, I'm still
13 practicing medicine. I have office practice as well as
14 hospital practice and enough number of committees and
15 boards around town that get to interact with physicians
16 with all different levels and all different specialties
17 and sub-specialties.
18 I think the intent of competency -- One thing
19 we have to be very clear about is protection of public
20 from physicians is not the intent of the legislature.
21 Physicians are there to protect the public.
22 It isn't an adversarial position.
23 Physicians are -- their very business is
24 protecting the public.
25 I think competency of physicians -- And we
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1 have discussed this one small component of it which is
2 the education component and their medical skills
3 component of the physicians.
4 I think competency involves a lot more than
5 just that. And the problems are lawsuits that we see
6 that are legitimate. They result, not so much from
7 their education and skills, more so from other factors
8 that are involved in the care the patients.
9 And I think that it will -- this board would
10 lack its responsibility if it did not address the whole
11 issue for the state.
12 It's not to protect the public so to say.
13 Education is one. Physical component is another. The
14 health of a physician and that's emotional health,
15 psychological health of the physician, and their ability
16 to function from day-to-day under the stresses that the
17 work -- their personal business stresses, and whether
18 they have a problem or a disease that would effect their
19 interaction with a patient or care of a patient.
20 I was heartened tremendously about the report
21 about the diversion program because the lack of support
22 was very disappointing that we are not getting anywhere.
23 And that was an extremely important program as far as
24 getting the physicians when they are not in the
25 physical, emotional, mental state or disease state to
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1 provide the care that the patients deserve to get them
2 out of the system and put them in a system and
3 rehabilitate them back to the system when they are able
4 to do that appropriately.
5 I think from an educational perspective, there
6 is lot happening at the national front. But if you take
7 the situation the way it is right now we still stand
8 ahead of the group as far as the rest of the union is
9 concerned. And we have a three-year program that we
10 have to have before we grant a license to somebody. And
11 then, of course, we do have the continuing medical
12 education that we require as part of it in their own
13 specialties.
14 The only component that I don't know what
15 purpose it serves or who are our ethics that we have out
16 there. And I haven't seen anything that tells me that
17 has done any good so far unless we can improve upon that
18 in some way.
19 We do need some sort of standardization that
20 has been voiced by Dr. Titus. Maybe it is being done.
21 And we see a lot of noise at a national level that every
22 board is considering doing and in fact some boards have
23 put into place. They have been ahead on this.
24 But so are the other boards considering
25 national guidelines. And I don't think there is any
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1 urgency or emergency to take sort action that is
2 halfhearted at this point.
3 That doesn't take away my admiration that
4 Dr. Baepler and his committee has done. And I commend
5 them tremendously for the hard work that they put into
6 produce the document that they did.
7 But my voice strongly is against this at the
8 present time. And as Dr. Montoya suggested we should
9 put this work aside for the time being, gather some more
10 information and wait for the time and if such a time
11 does arise to see what is best for this state and then
12 we should take the appropriate act at that time.
13 PRESIDENT HUG-ENGLISH: Thank you. Any
14 further discussion by any board members? Okay.
15 If not, then I would accept a motion on behalf
16 of these proposed changed regulations.
17 DR. MONTOYA: I would like to make a motion
18 that we table this regulation for the time being.
19 DR. BAEPLER: Second.
20 PRESIDENT HUG-ENGLISH: Okay. There is a
21 second. There is a motion and second to table
22 indefinitely this proposed change in regulation. All in
23 favor?
24 THE BOARD: Aye.
25 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
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1 in favor of the motion. Motion carries. So at this
2 point we have tabled indefinitely the proposed change in
3 regulation for continued competency.
4 And I want to thank Dr. Baepler and his
5 committee for all the time and effort that has gone into
6 this.
7 I think we need a little break. So we will
8 take a five or 10-minute break. Thank you.
9 (Recess was taken.)
10 PRESIDENT HUG-ENGLISH: I think we are going
11 to move this along because we have lots to do today.
12 We will move forward with agenda number five,
13 consideration by the audit performed by the federation.
14 And, Mr. Lessly, I will let you start us off
15 on this.
16 MR. LESSLY: At the president's instruction we
17 have reviewed the audit prepared by the State Medical
18 Board we also reviewed the paper from the Clark County
19 Medical Society. There are some things in this audit
20 that are advantageous for this board to implement.
21 There are some things in this audit that don't
22 do much for this board from a management standpoint or a
23 cost standpoint.
24 There are some things in this audit that will
25 require additional legislation.
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1 Since Tony Clark is going to be the person who
2 has to deal with any changes that may occur as a result
3 of the audit, let me ask him to give you the staff's
4 report and our position with respect to the audit.
5 He is going to go through this point by point.
6 When he is through, we need to know from you what it is
7 you want us to do as a result of the audit, whether it
8 be added to the legislative package in June or
9 implemented in some other fashion.
10 So let me let Tony go through it step by step.
11 MR. CLARK: I'm ready to start off and anyone
12 who wants to follow along, I'm starting off on page
13 seven because there are some recommendations throughout
14 the audit report that I will address and give you the
15 staff's recommendations.
16 Since the staff has had this audit in
17 possession just after the December meeting, we have
18 taken some steps to implement some of these things to
19 see if they would work and if we could do them and if
20 they are advantageous just to see how they would operate
21 waiting for this meeting for the board to tell us what
22 the board's desires are in this respect.
23 So starting out on page seven at the bottom
24 says, "The board should implement a system of assigning
25 priorities to investigated cases that suggest risk to
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1 the public. A simple system of priorities can be
2 implemented by high, medium and low priority assigned
3 and tracked through the board's database management
4 software."
5 The staff, subject to the board's
6 recommendation and direction, has already done this.
7 The board has a software program called Licensure 2000,
8 and it has already been adapted to high, medium and low
9 priority that can be assigned to every file that is
10 opened. And the investigation people are doing that now
11 and can continue to do that if the board directs them to
12 do so.
13 Going over to page eight at the top, "Open
14 cases should be reviewed at regular intervals in
15 structured process including the executive secretary
16 and/or deputy executive secretary, the chief
17 investigator, medical reviewer and the general counsel."
18 Deputy general counsel currently is meeting
19 weekly with the chief of investigations to review cases,
20 files, and procedures. And we have implemented a
21 monthly meeting now between the deputy executive
22 secretary, deputy general counsel, the chief
23 investigator and all of the investigative staff.
24 And we have had two of those thus far, two
25 monthly meetings thus far, where once again we discussed
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1 the cases, the files, the procedures, and prioritization
2 of those cases. And if the board wants, we will
3 continue those meetings on a regular basis.
4 Going down toward the middle of the page, "The
5 board has recently increased its investigative staff. A
6 reasonable portion of this resource should go to timely
7 communication with those who file complaints with the
8 board. While citizens who file complaints receive
9 immediate acknowledgment of the complaint and if a case
10 is closed, a closure letter, they will receive no other
11 correspondence in the form of periodic updates or
12 progress of the case if charges are filed."
13 What the investigators have started to do in
14 addition to sending out the initial letter confirming
15 that we have received the complaint and are opening an
16 investigation, they are now following up with a personal
17 telephone call to each one of the complainants to let
18 them know I'm the investigator who is involved in this.
19 I have opened an investigation file. You have anything
20 to add, any additional facts, any additional complaints,
21 any additional evidence, please communicate with me.
22 Here is my phone number and extension.
23 In addition, they have added a particular
24 system whereby they will communicate in writing with
25 every complainant every 45 days to let them know what
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1 the status is of the complaint going through the
2 investigative process.
3 They will also then send letters advising the
4 complainant if the matter has been passed by the
5 investigative committee and is going to a hearing and
6 will provide a copy of the complaint to the complainant
7 and let the complainant know the date of the hearing
8 before the hearing examiner. If the board directs us to
9 do that, we can do that. We have started that as an
10 implementation process and can carry it forward.
11 Down toward the bottom of the page, "A letter
12 should be sent to the source when formal charges are
13 brought with a copy of the charges and notice the date,
14 time, and place of the hearing and communicate the right
15 to be present at the public proceeding. The letter
16 should also list the contact name of the board at the
17 board office for questions."
18 As I said, we are already doing that and can
19 continue it if the board directs us to do so.
20 Going over then to page 10 toward the bottom,
21 "The board should retain a list of hospitals, clinics,
22 and other medical facilities licensed in the state from
23 the Bureau of Licensing, Nevada State Health Division.
24 The board should periodically remind hospital
25 administrators and chiefs of medical staffs of the
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1 facility reporting requirements."
2 The chief of investigations has communicated
3 with chief administrators of every hospital and clinic
4 in the state thus far. And he is establishing with
5 every chief administrator a cordial and communicative
6 relationship. And we feel that will result in hospitals
7 and clinics making those reports that are necessary when
8 a physician has been disciplined in the hospital. In
9 addition -- And we can continue to do that if the board
10 directs us to do so.
11 In addition, we sent out a letter to the
12 president of each of the county medical societies
13 introducing the board, introducing me as the deputy
14 executive director, and telling them and reminding them
15 the medical society's responsibility to make reports of
16 any malpractice cases or discipline that has been
17 rendered to any of the doctors in any of the local
18 hospitals. And I'm sure that they will be following up
19 with that information. And we can continue to do that
20 in each one of the news letters if the board directs us
21 to do so.
22 Going to page 12, one of the things that the
23 audit said, "Second, reviewing courthouse records is
24 redundant. Assuming statutory compliance with reporting
25 requirements this check should be unnecessary. The
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1 board should abandon review of county court records."
2 The investigators review the filings of all
3 malpractice cases, and we don't feel that we can afford
4 to have one fall through the cracks if the county clerk
5 or if the doctor or if the insurance company failed to
6 report.
7 One of the concerns was that you would have
8 multiple files on the same -- for the same incident
9 coming one from the insurance company, one from the
10 county clerk, one from the doctor, one from the
11 insurance company.
12 The investigative staff is only opening one
13 file. And if other sources come in concerning that same
14 file, they don't add four files. They have one file.
15 They just confirm the status of the information, and we
16 will continue to do that.
17 "The existing penalties for insurance
18 companies and physicians who failed to report
19 malpractice claims, settlements and judgments are
20 adequate and significant should they be pursued."
21 If the board wants, we can pursue this further
22 for some kind of punitive action. But I think that with
23 the steps that the staff has taken thus far, if the
24 board affirms those, we will not have that difficulty.
25 And we won't be having to pursue any punitive measures
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1 with either insurance companies or doctors because they
2 will be reporting and we will have the information.
3 Going down a little further, "One approach to
4 simplify the process would be to modify NRS 630.307 by
5 adding to those items that are reported by clerks of
6 court as a provision to report malpractice claims as
7 well as liability judgments to the board."
8 If the board directs us to, we can ask the
9 legislature to make that amendment to the statute.
10 In the next independent paragraph, the last
11 one on the page, "These cases need to be consolidated
12 through a computer system when initially entered to
13 eliminate opening multiple investigations."
14 As I indicated to the board, we are already
15 doing that.
16 Page 13, first independent paragraph,
17 "Furthermore each case reported by the clerk of the
18 court or the insurance company should be checked to see
19 if the licensee self reported. The investigative
20 committee should be informed of a failure to report. A
21 discipline should be levied as a matter of routine."
22 If the board directs us to, we can do this.
23 The next paragraph, "Additionally the
24 legislature should consider incentives to motivate
25 plaintiff's attorneys and victims of malpractice to file
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1 complaints with the board earlier in the process such as
2 isolating board action or lack of board action from
3 having any impact or outcome in a civil tort case."
4 And then go down a paragraph. "There may be
5 concern about jeopardizing a legal case if the board
6 intervenes as well as reticence to alert the board to a
7 claim because if the board closes a case it may be
8 perceived as to negatively affect the civil case.
9 One remedy may be statutory language that
10 lowers proceed barriers to board involvement such as
11 language providing that the presence of absence or board
12 action or involvement has no bearing on a civil case and
13 may not be used as evidence."
14 Once again, if the board directs, we can ask
15 the legislature to make that legislative change and can
16 implement that.
17 Going to page 14, right at the top, "The
18 legislature should consider reestablishing a properly
19 funded organization to perform the functions of the
20 medical dental screening panel.
21 The MDSP findings were useful to the board as
22 a processing tool. The benefit -- this benefit is now
23 lost to the board and it must now scour many more claims
24 to identify those that should be prosecuted.
25 The legislature should restore a properly
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1 funded successor to the MBSP while insisting that its
2 procedures facilitate the process of dealing with
3 complaints rather than hindering the process
4 unnecessarily."
5 The staff supports that and we can pursue it
6 with the legislature if the board directs us to do so.
7 Finally, "The board should periodically ask
8 the entire in-state licensee population via its
9 newsletter for physician volunteers for pure review.
10 Pure review by a qualified expert is usually
11 necessary to meet the board's evidence standard in a
12 hearing. A pure review establishes prevailing medical
13 practices and is necessary to identify practices falling
14 below those standards. Pure review is therefore a
15 necessary part of board operations."
16 Staff plans to request in each of its
17 newsletters of each of the licensees that they consider
18 volunteering for pure review and remind them that they
19 do get continuing medical education credits for serving
20 at a pure review.
21 DR. BAEPLER: They get a reduction in their
22 requirements.
23 MR. CLARK: They get a reduction in their
24 requirements.
25 In the next paragraph it says, "Physician
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1 licensees should be encouraged to participate in the
2 process as part of their professional responsibilities.
3 While the board offers an incentive to licensees by
4 offering continuing medical education credits, wider
5 solicitation would yield more volunteers."
6 And we will attempt to do that if the board
7 directs us in each and every one of our newsletters.
8 Going over to page 15, second paragraph, "The
9 board has made no enforcement effort to ensure accurate
10 reporting by those entities outside of its jurisdiction.
11 The board should obtain current mailing
12 addresses of all the hospitals and treatment facilities,
13 et cetera."
14 As I indicated, Doug Cooper, the chief of
15 licensing, has communicated with the administrators of
16 all the hospitals and major clinics within the State and
17 is establishing a rapport. And if the board directs us
18 to, we will continue that operation.
19 DR. BAEPLER: That puzzles me. They were
20 asking us to increase an enforcement effort over
21 entities that are outside of our jurisdiction. I don't
22 think we can do that.
23 MR. CLARK: We can. We educate them to
24 provide us with the information, and that's what we are
25 trying to do.
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1 DR. BAEPLER: That's not enforcement.
2 MR. CLARK: No --
3 MR. QUINN: There are enforcement provisions
4 put into the statute when you report the violation of
5 people who do have and then there are sanctions that can
6 be imposed for their failure to report.
7 MR. CLARK: Going down to the last paragraph,
8 "It is logical to assume that most citizens in Nevada
9 would want the board to take action on the license of a
10 physician convicted of a murder or serious sexual
11 offense whether or not the crime directly related to the
12 practice of medicine.
13 However, the effect of recent statutory change
14 is to remove the board's ability to act on a license in
15 such matters. NRS 633.01 should be revised to restore
16 the statute to its earlier status by including
17 conviction of a felony and any offense involving moral
18 turpitude as a basis for discipline or denial of a
19 license."
20 The staff concurs and if the board directs, we
21 will seek that reamendment to the statute.
22 Unprofessional conduct should be added to
23 Chapter 630 of Nevada Revised Statutes as ground for
24 discipline and/or license denial.
25 "The board should be authorized to define
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1 unprofessional conduct by regulation so it may act to
2 protect the public when the legislature is not in
3 session."
4 Once again, if the staff concurs and if the
5 board directs us to do so, we will seek that addition to
6 the Nevada Revised Statute.
7 Going down right under public, paragraph F,
8 talking about the audits. The auditors --
9 DR. ANWAR: Just a question. How would the
10 board, if it would be the board's responsibility to,
11 define what is unprofessional conduct? Although it is
12 -- that term is mostly used in the profession and there
13 seems like there may be some gray areas in what is
14 professional and what really is not professional.
15 How do you define unprofessional conduct in
16 black and white if you are supposed to take action based
17 on that?
18 MR. CLARK: What we would anticipate doing is
19 talking to the federation and getting language from
20 other states that have already adopted the definition of
21 unprofessional conduct and then putting out a draft
22 regulation or workshops in both Las Vegas and in Reno
23 for comment and then trying to adopt a regulation once
24 that definition has been approved.
25 DR. KINGSLEY: Mr. Clark, Dr. Kingsley down in
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1 Las Vegas. You could put the word in criminal to define
2 offense and that would be defined by previous statutes
3 in the past legally.
4 MR. CLARK: Okay.
5 DR. KINGSLEY: That's just a thought.
6 PRESIDENT HUG-ENGLISH: I'm sorry. If you are
7 not hearing us, please let us know. We are trying to
8 remember.
9 DR. KINGSLEY: We can hear Mr. Clark, but, for
10 example, we couldn't hear Dr. Anwar or the other
11 speaker.
12 PRESIDENT HUG-ENGLISH: Thank you.
13 DR. KINGSLEY: So, Mr. Clark, did you hear our
14 suggestion here putting the word criminal defense to
15 define what that means?
16 MR. CLARK: Yes.
17 DR. JONES: Was that in regard to the
18 unprofessional conduct or were you talking about
19 something else?
20 DR. KINGSLEY: The moral turpitude.
21 MR. CLARK: Moral turpitude, yes.
22 DR. KINGSLEY: Making a criminal offense
23 involving moral turpitude.
24 DR. BAEPLER: This is Don Baepler. Seems to
25 me that these fall roughly into three categories. Some
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1 of them require statutory changes. We are going to
2 consider those in June.
3 Some of them involve perhaps simply a change
4 in regulation which we can adopt.
5 Some of them are simply policy changes like
6 keeping better contact with the complainants and so on.
7 I wonder if you could break them into those
8 three categories so we can at least require those
9 requiring statutory changes at the June meeting with the
10 other statutory items.
11 MR. CLARK: Yes. I can and I will.
12 DR. BAEPLER: Break them out, and we can take
13 them up one by one.
14 MR. CLARK: Moving forward. Under F, "The
15 auditors conducting the annual financial audit do not
16 currently present the annual audit directly to the
17 entire board.
18 The report is instead presented to the board's
19 secretary treasurer and in accordance of law a copy of
20 the audit -- excuse me, is sent to the legislature.
21 The board should create an audit committee to
22 whom each audit will be presented in person.
23 Additionally, the auditors should be required to
24 indicate in writing to the board whether or not a
25 management letter has been prepared. The auditor should
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1 be required to submit the management letter at the same
2 time that they submit audit and each recommendation
3 contained in the management letter should be explained,
4 discussed and accepted or rejected in a public session
5 of the board."
6 Currently staff is opposed to forming an audit
7 committee. I don't think it's necessary. But the
8 process currently is that once the audit is completed it
9 is presented to the secretary treasurer of the board and
10 the executive secretary.
11 The secretary treasurer then presents the
12 audit to the board at a public meeting.
13 Management letters are presented to the
14 managing group of the board, that would be the executive
15 secretary. That management letter is then sent to every
16 member of the board and a letter covering that advises
17 the board that, for instance, for the last management
18 letter each item in the management letter has already
19 been complied with and there are no more further
20 problems.
21 In past audit management letters, the cover
22 letter would say we agree with A, B, C and we are
23 implementing them. But D and E wouldn't work for us for
24 these reasons.
25 We also think that the management letter is
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1 given to management to make the operation of the
2 organization better. That is not a public record, and
3 we don't think it ought to be discussed publically. It
4 is for the board to utilize to direct the staff to do a
5 better job and as a consequence we would oppose making
6 that public.
7 DR. BAEPLER: And one further note, they don't
8 always have a management letter.
9 MR. CLARK: That's true. They don't always
10 provide a management letter.
11 Now going over to page 17, Other findings and
12 recommendations. So this is where they make more
13 specific recommendation. Under the first
14 recommendation, Make public board orders and statement
15 of charges available to the public at no cost
16 electronically.
17 The customer clicks on the record and it is
18 displayed on the customer's computer screen by Adobe
19 Acrobat software. The Adobe Acrobat Reader software is
20 free. The process makes public records immediately
21 available to the customer where they can be downloaded
22 and printed with user resources.
23 The board has Adobe Acrobat software. We can
24 implement this if the board directs us to do so.
25 DR. ANWAR: Who is the customer?
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1 MR. CLARK: Whoever wants to get a copy of
2 lists of doctors who have been disciplined. Anybody who
3 wants to get a copy of one of the application forms, any
4 member of the public who wants information about his or
5 her doctor. That's who the customers would be. And we
6 would make it available, of course, on the Internet
7 through the Adobe software. They can get copies.
8 The next recommendation on page 18, "Even
9 though the newsletter is an excellent publication minor
10 changes could be made to enhance its value as an
11 education tool to inform physicians of the meetings of
12 the board and its role in protecting the public. The
13 newsletter also serves the important role of reminding
14 physicians of their professional responsibilities.
15 The newsletter would be more effective if
16 professionally redesigned and enhanced to enhance
17 readability.
18 Members of the board staff should arrange
19 speaking engagements before physician and specialty
20 groups and hospital and medical staffs to inform
21 physician population of issues facing the medical
22 disciplinary licensing community and to explain how the
23 board works.
24 Board members and staff would also regularly
25 address community groups, for instance, rotary, seniors,
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1 citizen advocacy groups throughout the state."
2 If the board wants, we can have the newsletter
3 done professionally, designed and printed. If the board
4 directs, the staff can make itself available to go out
5 and speak to hospital groups, doctor groups.
6 The next recommendation --
7 DR. TITUS: Before we go on, along that line
8 of the newsletter when I read that, I also have felt for
9 some time that we are not good at public relations with
10 the physicians that we license, PAs, respiratory
11 therapists.
12 And on that note I brought -- the nursing
13 board had some of these issues contacting their
14 personnel or peers or people they licensed. And they
15 have just started a different newsletter that they have.
16 And I brought that to give to this board. You may have
17 already seen what they have done.
18 And our nurses had it at our hospital, and I
19 saw this and I thought what a nice document. It wants
20 you to read it.
21 The nurses wanted it back when I got done with
22 it today so that they could finish reading some of the
23 articles in here.
24 So different than what we have is the letter
25 that we send out on a quarterly basis that I look at
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1 because I'm involved with the board. But prior to being
2 involved with the board, I never looked at it. I think
3 it would be a good idea for us to develop a different
4 type of newsletter.
5 MR. CLARK: Okay. The next recommendation
6 still on that page, "Hire a full-time public information
7 media communication specialist and implement a proactive
8 communications program that explains the board, its
9 mission and what it does to all of the board's public on
10 an ongoing and regulatory basis. Additionally there is
11 an opportunity to provide this function with little or
12 no budgetary impact."
13 The board currently funds public service
14 announcements at $60,000 annually. The benefit of these
15 PSAs, are best, anecdotal.
16 Let me first observe that the auditors did not
17 look at any of our public service announcements. Both
18 the president and the executive secretary made the offer
19 to provide those. We had the public service
20 announcements here for them to review, and they refused
21 to review them.
22 Secondly, with respect to a full-time public
23 information officer, the staff is opposed to that. I
24 don't know what a public information officer would do 40
25 hours a week. There just isn't enough work.
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1 And it would require, once again, a salary
2 with perks and pay of over $100,000 a year, another
3 office for office space and an additional computer
4 support.
5 And I think that if the board wants, we can
6 hire a part-time professional to put out a professional
7 newsletter and professionalize the brochures that we
8 print to send to all of the doctors' offices.
9 And if the board wants at the June meeting, it
10 could amend the executive secretary's job performance
11 description to add to it a potential to be the public
12 affairs person who could speak for the board and go out
13 and appear for the board, answer questions for the board
14 and make appearances.
15 Currently, only the president speaks for the
16 board, and that has worked out well for the board, I
17 believe.
18 Before the executive secretary should go out
19 and speak for the board I think that the individual
20 would have to have the presence, direction, and
21 blessing. But you could add to the job description of
22 the executive secretary that additional duty and that
23 would not be a burden, I don't believe, to the executive
24 secretary.
25 DR. BAEPLER: I asked myself the same
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1 question. What would I do if I was the PI, public
2 information officer, PR person, or whatever, eight hours
3 a day. And I couldn't think of how I would occupy my
4 time.
5 If you look at the state web page go to boards
6 and commissions under state government, my goodness
7 there is a lot of information. If you try to distill it
8 out, go to our own web page. We list all the regulatory
9 boards dealing with the health profession. There is 17.
10 And the only one I can find that has a person
11 like this is the nursing board. The other 16 don't.
12 And the nursing situation in any state
13 including Nevada has a whole host of different kinds of
14 problems.
15 So I agree with you. Certainly don't need a
16 full-time one. I agree that the executive secretary
17 should be able to speak for the board. I was not aware
18 that was not in your job description and that's just a
19 function of policy.
20 And any member can speak to the press as long
21 as they point out they are only speaking for themselves,
22 you know, as an individual. They are not representing
23 the board. That's what is reserved for the president.
24 MR. CLARK: The next recommendation down
25 toward the bottom of page 19, "More reliable information
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1 about the physician work force in Nevada is needed. The
2 board can provide useful data from within the State that
3 is needed by the legislature and others to make
4 work-force decisions.
5 The physician registration forms is an ideal
6 survey instrument. It generates 100 percent response
7 from active licensees and its accuracy is encouraged
8 virtue of penalties for false reporting."
9 The staff can implement this at any time if
10 the board directs us to do so.
11 Going over to page 20. "A competitive
12 non-cozy relationship with the state or any county
13 medical society is acceptable, perhaps even preferable,
14 given the contract provisions of the board and the
15 professional societies. But neither should be
16 antagonistic to the other appreciating the distinctive
17 role and responsibilities of each.
18 A medical society is an interest group. A
19 board is a regulatory agency with specific statutory
20 authority and limitations. There are plenty of
21 opportunities for these interests to clash.
22 The board should undertake a continuous and
23 ambitious program to make presentations describing what
24 the board does and why and how it operates in every
25 local and county medical association and large hospital
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1 medical staffs.
2 Similar presentations should be scheduled with
3 rotary clubs, Lions, Kiwanas, chambers of commerce,
4 citizens groups, et cetera."
5 Once again, staff can do this if the board
6 directs us to do so.
7 Going on to recent statutory changes, grounds
8 for disciplinary action. "Some recent statutory changes
9 diluted consumer protection provided by the board.
10 Under this new language the board is greatly
11 disadvantage in its ability to protect the public.
12 Recommendation: Restore NRS 63.301(1) to its
13 earlier status to reverse the recent statutory
14 limitation on felonies and moral turpitude offenses as
15 grounds for discipline or denial for licensure. Most
16 felonies are inconsistent with the character required of
17 a healer and one should not condone or appear to condone
18 improper sexual activities which is what the elimination
19 of moral turpitude implies.
20 The state granted privilege of licensure as a
21 provision for them a higher level of character."
22 The staff approves this and would seek to
23 change to the statute if the board directs us to do so.
24 Almost at the end. Page 22, Recommendations.
25 This talks about licensure by endorsement.
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1 While they suggest -- the audit suggests that
2 the accepted change provisions for core credentials
3 should be repealed.
4 The staff has no recommendation on this at
5 all.
6 The board has already addressed this problem
7 with the amendment that it made to its regulations at
8 the last meeting and another proposed amendment which
9 will come up later today dealing with recertification
10 and sub-specialties. So the staff has no recommendation
11 on that one.
12 And finally down at the bottom there,
13 "Recommendation: Move to an annual process of
14 registration based upon birth month. This would purge
15 inactive licensees and outdated addresses sooner,
16 provide critical self-reported information on the
17 registration form in a more timely fashion and make for
18 a more efficient processing of transaction. A change in
19 the registration interval requires a statutory change."
20 The staff opposes this recommendation. We
21 don't see that there is any benefit to either licensees
22 or to the board by having an annual registration.
23 And, in fact, it would require the board to
24 hire an additional license person who would do nothing
25 but do renewals of registrations. And we don't think
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1 it's necessary. And that puts an annual burden on
2 licensees to reregister as opposed to doing it every
3 other year which I think is an easier way to operate.
4 "The board should also implement a system of
5 electronic registration for licensees via the internet,
6 accept credit card payments and would provide
7 significant convenience to physician licensees, lower
8 manual overhead for the board, and provide prompt,
9 accurate registration information to the board
10 electronically."
11 If the board directs us to do so, we can do
12 the reregistration electronically. The only problem
13 that I see would be how you certify that you have
14 completed your 40 hours of continuing medical education.
15 But that's not a problem that can't be resolved by the
16 time we go into the relicensure cycle.
17 DR. TITUS: Can I address that? One of the
18 things that -- I hate to keep throwing out family
19 practice, but I happen to be proud of that organization.
20 We do on-line-CME documentation now that, I
21 think, would be fairly easy to send that as a note to
22 when a doctor registers on line they record, you know --
23 you go in, you record what meetings you have done, they
24 document it, and then they post it. There is a little
25 time there, but it is happening. I think many of the
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1 professional organizations are doing on-line-CME
2 registration. I think it would be fairly easy to add
3 that.
4 MR. CLARK: All you would have to do is add a
5 certificate. You would not have -- for instance, if you
6 do them electronically, you would not have the doctor's
7 signature. If you require the certificate in the
8 doctor's name that he or she filled out the form for
9 reregistration and did the CME, I think that would
10 suffice.
11 And the final one, "The board should do
12 primary-source verification of criminal history. It may
13 contract with a private vendor who preserves criminal
14 records. But there is disadvantages to this approach.
15 The best system currently available to a qualified
16 agency such as the medical licensing board is the
17 Federal Law Enforcement System National Crime
18 Enforcement Center maintained by the Department of
19 Justice through the Federal Bureau of Investigation."
20 The staff supports a criminal background
21 check. In fact, the osteopaths took that through the
22 legislature and got authority to do that at the last
23 legislative session. We might even want to consider
24 initially for applicants drug tests as well as criminal
25 background investigations.
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1 DR. BAEPLER: With fingerprints?
2 MR. CLARK: You would have to take
3 fingerprints because that's how the FBI does its
4 background investigations.
5 PRESIDENT HUG-ENGLISH: If I can comment on
6 that, that's been something that we have had
7 presentations about that has been requesting of this
8 board before.
9 I think that it's certainly looking like other
10 states are doing this and that, I think, that we are
11 really at a point where we are going to have to start
12 doing some of this and take that on as a board.
13 So I would support the staff's recommendation
14 that we begin doing that as well.
15 MR. CLARK: That concludes the presentation of
16 staff.
17 PRESIDENT HUG-ENGLISH: That's all?
18 MR. CLARK: That's it.
19 PRESIDENT HUG-ENGLISH: Dr. Anwar?
20 DR. ANWAR: I have a brief comment, and that's
21 a good presentation and recommendation from the staff.
22 But I would really like to know as to the
23 basis of these recommendations, although they are coming
24 from -- some of them from the federal as to what has
25 been adopted in other states. Do we have any
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1 information on that as to what is going on in other
2 states and what has already happened in other states?
3 MR. CLARK: I don't know the answer to that,
4 but I can certainly find it out and present it to the
5 board at the June meeting when I will also break out
6 those things that are staff recommendations, those
7 things which require statutory implementations, et
8 cetera, as Dr. Baepler requested.
9 PRESIDENT HUG-ENGLISH: Thank you, Tony.
10 There's been a lot of information presented.
11 I guess I would like the board's input on this as to
12 whether or not we want to approve what the staff is
13 already doing currently.
14 Some of the things that you indicated, Tony,
15 you have already taken steps to correct or proceed with
16 and whether we want to as a board authorize that to
17 continue.
18 And then there are some other things that we
19 really haven't instituted yet but would begin to
20 institute. So I see those as two separate things.
21 MR. CLARK: Yes.
22 DR. BAEPLER: However, there is nothing that
23 you have implemented as far as I know that I object to.
24 But we have had such a batch thrown at us. I
25 wonder if -- again, continue to do what you have
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1 implemented. In June when we consider all of these if
2 you can give us the essence of the changes that you have
3 instituted, we may want to tweak them a little bit. And
4 we can get all of our action ratified in June.
5 DR. LUBRITZ: I would second that.
6 MR. CLARK: If that's agreeable with your
7 staff I'm sure --
8 PRESIDENT HUG-ENGLISH: So what I'm hearing
9 then is that we would allow the staff to continue
10 implementing the things that they have already started
11 doing. And then in June we would have a more detailed
12 list of what those things are and maybe an update on how
13 that's going. And, in addition, the things that you
14 have elucidated so nicely today would be sort of laid
15 out for us as to which things we need to take action on
16 as a board, which things would require legislative
17 statutory change.
18 DR. BAEPLER: Just one example, I think I
19 remember that your having the investigative staff call
20 or write -- I guess, write to the complainants every 45
21 days?
22 MR. CLARK: Yes.
23 DR. BAEPLER: I have always advocated more
24 contact with the complainants. But given the nature of
25 the complaints we get, you can't put them all in one
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1 mold. In other words, every 45 days may be too frequent
2 for something that is really stretching out. But the
3 concept that you are implementing of more contact with
4 these people, yes, for sure. I would just like to see
5 the details of what you have implemented.
6 DR. ANWAR: Do you need a motion?
7 MR. CLARK: If we could, Doctor, please.
8 DR. ANWAR: I move that the changes that
9 already been made as far as the staff is concerned
10 should be continued until further notice as far as our
11 June meeting is concerned.
12 MS. KIRCH: Second.
13 PRESIDENT HUG-ENGLISH: Okay. There is a
14 motion that the changes that have been implemented up to
15 now be continued until our June meeting. And is part of
16 that motion that we then take a more detailed look in
17 June as to the other things that have not been yet
18 implemented?
19 DR. ANWAR: Yes.
20 PRESIDENT HUG-ENGLISH: Okay.
21 DR. LUBRITZ: That would still give us --
22 although we would continue what is currently being done
23 until the June meeting, we would still have the
24 opportunity to discuss even those things that have been
25 implemented.
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1 PRESIDENT HUG-ENGLISH: Absolutely. They will
2 all be laid out again so that we can take a look at it.
3 It's just from March to June they continue doing what
4 they have already started.
5 DR. LUBRITZ: Has that motion been second?
6 PRESIDENT HUG-ENGLISH: Yes. All in favor?
7 THE BOARD: Aye.
8 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
9 in favor of the motion. The motion carries.
10 I want to thank you, Tony, for that very
11 detailed analysis of that audit. And I want to make
12 some general comments about the audit.
13 The audit was a very favorable report of this
14 board certainly reinforces the fact that this board
15 works very hard in doing its regulatory job.
16 And I think we need to -- although we are
17 going through a lot of the very minor suggestions that
18 they have for improvement, we also need to remember that
19 this audit came back very supportive of all of the
20 efforts that this board is undertaking and the method in
21 which it does its work.
22 So I think that there is always room for
23 improvement. We are certainly open for suggestions.
24 I think some of the things you brought up
25 today, Tony, are good changes that we can certainly work
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1 to improve ourselves on. But we also need to remember,
2 and I want to reemphasize how much I appreciate each one
3 of you on this board and the work you do and the time
4 you devote to this process. So thank you.
5 Any other comments about the audit in general?
6 Okay.
7 Dr. Lubritz?
8 DR. LUBRITZ: If I may. May we also discuss
9 the opinion letter that we have obtained from --
10 PRESIDENT HUG-ENGLISH: That happens to be the
11 next agenda item. So we can do that right now. That is
12 the physician paper by the Clark County Medical Society.
13 And, Dr. Kingsley.
14 DR. KINGSLEY: Yes. Thank you,
15 Dr. Hug-English.
16 We appreciate this opportunity to officially
17 express our physician paper. I would agree with your
18 comments, Dr. English, that you just made. I think that
19 the board does work very hard and strives truly to
20 represent and protect the interest of the citizens of
21 Nevada.
22 And we do agree with many of the
23 recommendations that were made in the audit. And I will
24 not -- I don't want to duplicate what Tony has so ably
25 outlined for you. And we appreciate most of the changes
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1 and recommendations that he is making.
2 There are two items that we respectfully
3 disagree with, and I will just point those out.
4 We do believe that a public information
5 officer would be helpful, not necessarily a full-time
6 officer, perhaps part-time, 10 hours or 20 hours,
7 whatever would be reasonable. But we think that would
8 be more advocatious than the PSAs that are currently
9 being shown.
10 We do believe that the electronic registration
11 and licensure is worthy of pursuing and it could be done
12 biannually as we do now. And it could all be done, you
13 know, as of June 30th of each year so you wouldn't be
14 stretching staffs out throughout the year according to
15 birthdays.
16 We do believe that the financial audits and
17 the management audits should be presented to the entire
18 board in a public meeting. We feel strongly about that.
19 We concur or we believe that licensure via
20 endorsement should be continued.
21 And I'm not going to go into great detail on
22 these. You have them there. I'm stressing the bullet
23 points basically.
24 We would encourage, and I haven't heard this
25 mentioned, at least, at length. We encourage the board
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1 to access the National Physicians Databank information
2 proactively and on a routine basis for malpractice
3 awards or adjudications, and I'm not sure that is being
4 done. Tony, I don't remember you mentioning that.
5 We don't believe that every malpractice claim
6 needs to be investigated by the board. We think that
7 your resources would be better allocated elsewhere.
8 We do believe that's primarily because
9 approximately two thirds of those cases are dropped.
10 There are no awards made, no adjudications. So we
11 believe that your resources would be better spent
12 pursuing those cases where there is a payment or
13 adjudication rendered for those malpractice claims.
14 We concur with the Senate Bill 250, the spirit
15 and the letter of trying to encourage better behavior in
16 physicians by sending letters of concern or letters of
17 admonition for unprofessional acts that don't rise to
18 the level of official censure or disciplinary action.
19 Being a little more proactive there would be helpful.
20 We do think it should be considered, at least,
21 for the board to authorize the investigative committee
22 to receive and address source complaints as opposed to
23 having that come from the board itself which would free
24 up the board's time. In other words, delegating that
25 responsibility to the investigative committee to issue
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1 letters. You could seek an opinion from the LCB or the
2 AG on that from a legal standpoint, but we feel that is
3 something worth pursuing.
4 We also were concerned about the talk of
5 publishing on the website statements of charges against
6 physicians. As we all are aware, frivolous charges can
7 always be filed against physicians. So we would rather
8 that the findings of fact and the conclusions of the law
9 be published on the website as to all charges.
10 And I think that summarizes it briefly. Thank
11 you.
12 PRESIDENT HUG-ENGLISH: Thank you,
13 Dr. Kingsley.
14 Are there any comments from board members?
15 DR. LUBRITZ: Yes.
16 PRESIDENT HUG-ENGLISH: Dr. Lubritz?
17 DR. LUBRITZ: Well, Ed, thank you for that
18 information, but I have some questions that I would like
19 to get some information on and specifically from
20 Dr. Havens.
21 If this was an opinion letter, that was --
22 we'll put that in quotes for a moment -- of the Clark
23 County Medical Society, how is that promulgated? In
24 other words, how did you get the information from all of
25 the members of the Clark County Medical Society? And
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1 I'm not sure how many there were so you could get an
2 opinion from them of what you wanted to put in this
3 letter?
4 Was the audit sent out to all the members of
5 the Clark County Medical Society?
6 DR. KINGSLEY: No. When we undertake business
7 of the board, we don't do that either. We don't
8 routinely evaluate and ask for the opinion of every
9 member.
10 We are duly elected annually by our members.
11 And we, therefore, by force are their spokes people.
12 And they have elected us to fulfill that obligation.
13 So we don't individually poll every single
14 member of the society.
15 DR. LUBRITZ: Who did you poll?
16 DR. KINGSLEY: Well, this is a -- really comes
17 from the board which represents the members.
18 DR. LUBRITZ: Like who specifically on the
19 board did you poll?
20 DR. KINGSLEY: This is discussed at board
21 meetings. These issues are discussed at board meetings.
22 I don't record specifically who makes what specific
23 comments.
24 DR. LUBRITZ: Did you pin the letter or did
25 Dr. Havens?
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1 DR. KINGSLEY: It was a joint effort.
2 DR. LUBRITZ: Did he do most of it, or did
3 you?
4 DR. KINGSLEY: He wrote much of it, and I
5 added my two cents. I thoroughly reviewed this audit
6 myself. And, in fact, I took the initiative, and I sent
7 in my recommendations to him. And I believe much of
8 this was written after that. So I did initiate this,
9 yes.
10 DR. LUBRITZ: Okay. The reason I'm asking
11 this is I took some time and trouble to contact some of
12 your previous Clark County Medical Society past
13 presidents, officers, trustees, current trustees and
14 they pretty much didn't know much about this at all, the
15 ones I spoke to. I won't give you their names. I
16 called them. And I don't feel that I should do that.
17 But it wasn't a small number that I discussed
18 this with. I also asked them, I said, you know, Do you
19 have any problem. If you have had encounters with the
20 Nevada State Board of Medical Examiners, have you been
21 treated respectfully? Have you gotten any information
22 that you need? And each one of them told me, you know,
23 we have no problem with the board and the way it
24 conducts itself and the way it runs itself. And we
25 don't particularly have a problem. And we were kind of
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1 on the outside of this opinion letter and it was just
2 kind of presented to us.
3 So I'm getting two stories. And certainly I
4 have no reason not to believe those physicians with whom
5 I spoke.
6 So I'd like to just -- since Dr. Havens pinned
7 most of it, I would like to hear from Dr. Havens. He is
8 right there. Could he speak up?
9 DR. HAVENS: Sure. I got information from
10 Dr. Kingsley. We distributed the physician or
11 federation statement of board's audit information to our
12 board members and also posted it on our website.
13 And I wrote a first draft, and then it went to
14 Dr. Kingsley. And it underwent several redrafts and was
15 presented to the board, and the board voted unanimously
16 to adopt it.
17 DR. LUBRITZ: Well, I think that's true
18 because when I spoke to the boards of trustees, et
19 cetera, that I just went over, they said it was briefly
20 brought up and that they weren't very familiar with it.
21 I asked them specifically, Did you read
22 through the audit? And they said, No, not really. We
23 didn't really have the time to do that.
24 So what I'm basically saying is and, Ed, I'd
25 kind of like to leave you out of it. I don't want to
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1 shoot the messenger, and it looks like you are the
2 messenger. As far as I know there is just no problem.
3 I would bring up to you that there are enough
4 members here with enough longevity to realize that the
5 Nevada State Board of Medical Examiners never really had
6 any schisms, any problems with the Clark County Medical
7 Society until the advent of your executive director in
8 his capacity and new attorney.
9 There was never a problem. There only seems
10 to be some schisms since he has begun his tenure there.
11 I have been asked by some of the previous
12 presidents, What can we do to make things better between
13 the two of us, and we were unaware that there was a
14 problem.
15 It only occurred when there began writings,
16 lectures, opinions from other people. And this isn't me
17 talking behind Dr. Haven's back. I have told him this
18 to his face.
19 DR. HAVENS: You have, and I appreciate your
20 opinion.
21 DR. KINGSLEY: And as far as I am concerned,
22 there is a good relationship between the BME and Clark
23 County Medical Society.
24 And, in fact, what you are saying comes as
25 somewhat of a surprise. I'm aware certainly there may
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1 be some personality differences between our executive
2 director and some members or staff members of the BME.
3 I'm certainly aware of that.
4 But on a professional and official basis, I
5 think we have worked well together. And I think we
6 still are working well together. I think the changes
7 recommended to be considered are not adversarial. As I
8 said in my opening remarks, I think that Tony Clark has
9 already addressed many of these issues and favorably as
10 far as we are concerned. There are only a few we
11 disagree with.
12 As I also said, I also agree with the comments
13 Dr. Hug-English have made in regards to the board. So
14 that's our official stance.
15 DR. BAEPLER: I think one of the problems is
16 we get representations that the Clark County Medical
17 Society recommends this or opposes that. And the
18 question is what's the process whereby they come to that
19 decision or conclusion?
20 And the board consists of, what, maybe four or
21 five people?
22 MR. KINGSLEY: No. There is a dozen. I think
23 18.
24 DR. BAEPLER: And we could assume, therefore,
25 that when representations are made to this board, that
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1 the Clark County Medical Association has taken a
2 position or something that that body is informed on the
3 measure and has expressed that opinion. Is that a
4 correct conclusion?
5 DR. KINGSLEY: Yes. Just the same as, for
6 example, when material is handed out to the Board of
7 Medical Examiners to be discussed at an upcoming meeting
8 that they each responsibly take that information and
9 review it and adjust it and then make input on that.
10 And I can't guarantee that on our board
11 members. I can't guarantee each of our board members
12 did, in fact, read the audit. They were provided with
13 it. I can't guarantee they have done that, but, yes.
14 DR. BAEPLER: The process was there.
15 PRESIDENT HUG-ENGLISH: I'd like to pull this
16 back into the issue we have before us and, that is, that
17 you had a few recommendations. I don't see that many
18 that really differ from what has been brought forward
19 already.
20 And this board has already decided we'll kind
21 of bring this back up in June to look at what has been
22 done up to now and maybe perhaps some things we need to
23 do going forward as of June.
24 So we have taken note of these, and we will be
25 discussing it in June. And I thank you for your input
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1 on that.
2 DR. KINGSLEY: Thank you.
3 DR. HAVENS: Thank you very much.
4 PRESIDENT HUG-ENGLISH: Okay. Let's see. Do
5 we have Mr. Fisher down in Vegas? Is he there?
6 MR. FISHER: Yes.
7 PRESIDENT HUG-ENGLISH: Okay. Mr. Fisher, do
8 you want to make your presentation to us about the
9 Nevada Broadcasters Association?
10 DR. KINGSLEY: He is making his way over to
11 the microphone.
12 PRESIDENT HUG-ENGLISH: Okay. Thank you.
13 DR. KINGSLEY: Do you want item eight before
14 item number seven?
15 PRESIDENT HUG-ENGLISH: We did seven earlier.
16 MR. FISHER: I just want to disagree with the
17 immediate past speaker, public information officer has
18 absolutely nothing to do with PSAs or NCSAs. They are
19 two totally different kinds of functions. And I just
20 think that the issue of a public information officer,
21 that's one issue.
22 The issue that I want to talk about is the
23 public awareness campaign which we are calling the
24 communications campaign.
25 Madam Chairman, my presentation today is
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1 really no different than my presentation was three
2 months ago.
3 The only difference really is the fact that we
4 have had the opportunity -- Tony and I had the
5 opportunity to meet several times. And I did have the
6 opportunity to meet with the sub-committee together with
7 one of my staff members, Tashana (phonetic) who is here,
8 who had submitted some scripts just to give a rough
9 idea.
10 If you want, I'm more than happy in very brief
11 terms to review the four items that I sent to Tony at
12 the end of the day yesterday.
13 I just want to explain to everybody that I
14 have been on the east coast for three weeks and came in
15 this morning.
16 PRESIDENT HUG-ENGLISH: A little jet lagged,
17 are you?
18 We did receive -- the board members received
19 that this morning. We have not had a lot of time yet to
20 review the scripts that you submitted. Do you want to
21 talk --
22 MR. FISHER: Let me talk about the four points
23 and then the board, as always, can really do whatever
24 they want.
25 The Nevada Broadcasters asked three months ago
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1 and is again asking today to get a twelve-month
2 commitment from the board of medical examiners.
3 It is very difficult to put together a
4 comprehensive program especially if you bring in public
5 awareness where we are not sure from month to month what
6 is happening. It gives no opportunity to build
7 consistency. It gives no opportunity with which to
8 develop.
9 It is obvious from your meetings that there
10 are different needs, and the needs change as the year
11 develops. That is why, skipping down to item number
12 four, Nevada Broadcasters wants to do nine television
13 commercials and they want to do nine radio commercials
14 because the issues are going to change.
15 And what we propose -- we didn't propose it.
16 What the sub-committee came up with which was item
17 number three is that immediately we would put on the air
18 three different messages. One of them was the mission
19 of the board, exactly who we are and what we do.
20 The second is talking about the doctors. The
21 doctors in this state are good doctors, are professional
22 doctors.
23 And the third, of course, is directing people
24 to the website. And I would presume each of those
25 messages would still want to include the telephone
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1 number that has been so successful which I think was not
2 mentioned at the meeting three months ago and the number
3 of calls that are coming into the office on a day-to-day
4 and week-to-week basis.
5 So number one, the first thing that Nevada
6 Broadcasters is proposing is that we do a 12-month
7 campaign.
8 The second thing in doing that I don't believe
9 and I don't think the Nevada Broadcasters Association
10 believes that one size fits all is the way to market
11 public communication and public awareness. That was
12 something I had also spoke about three months ago.
13 I think we need to target northern Nevada. I
14 think that we need to target southern Nevada, and I
15 think we need to target rural Nevada. That was, I
16 think, the main point of number two.
17 In terms of number four, the Nevada
18 Broadcasters gave a proposal in terms of doing a
19 12-month campaign. And the Nevada Broadcasters gave a
20 proposal in order to do the production. And those
21 figures, again, are to give you nine commercials so that
22 there that are three commercials running on a television
23 in a quarter and three commercials running on radio for
24 a quarter and each quarter those commercials change
25 because you want to keep the message fresh.
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1 Plus the fact your board has certain things
2 that they may want to be pushing right now such as the
3 three the sub-committee recommended. You have to have
4 that flexibility. And I don't want to run the same
5 thing for a year.
6 And that's basically it. From the meetings
7 that I had from Tony and from the meeting I sat in and
8 Tashana (phonetic) and I sat in with the sub-committee.
9 PRESIDENT HUG-ENGLISH: How long would it take
10 to develop these spots?
11 MR. FISHER: Once the board approves of the
12 scripts, radio can be done probably within 10 days.
13 Television can probably be done within two weeks.
14 PRESIDENT HUG-ENGLISH: Okay. Well, it was
15 also pointed out that the dollar amount for this new
16 contract has gone up a bit. Do you want to discuss
17 that?
18 MR. FISHER: Yes. As a favor to
19 Mr. Rosencrantz, going back several years ago, Nevada
20 Broadcasters discounted what we would normally charge a
21 client.
22 The fact is that by raising you from $5,000 to
23 $6,000 you are still being discounted because the
24 current ads now should be, especially for a statewide
25 television and radio, approximately $7500.
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1 Again, because we were going month by month or
2 quarter by quarter and is it going to continue, is it
3 not going to continue. If we are going to do it, we are
4 going to do it right and that's the bottom line.
5 The bottom line is what you are being given is
6 really what you should be given for the kind of job that
7 needs to be done.
8 PRESIDENT HUG-ENGLISH: Okay. Thank you very
9 much.
10 Any discussion by any of the board members?
11 Dr. Montoya?
12 DR. MONTOYA: Steve Montoya. I met you down
13 in Las Vegas. I really have no problem with your fees
14 going up from five to six thousand. We all realize cars
15 have gotten more expensive as has office space as have
16 malpractice. And I personally don't think the increase
17 by a thousand dollars a month is -- were all that
18 significant for what we are seeking and for the money
19 value and for the value we are receiving from all of
20 this.
21 MR. FISHER: I am going to be in Reno Sunday,
22 Monday, Tuesday, Wednesday to Thursday morning. If
23 there is anybody in Reno that wants to meet together, I
24 am certainly available to do so.
25 PRESIDENT HUG-ENGLISH: Okay. Thank you very
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1 much.
2 I think because this board has really not had
3 a chance to take time to look at these spots, we are
4 going to defer making a decision today.
5 What I might do, though, is suggest that we
6 bring this agenda item up maybe tomorrow morning and
7 think about whether we want to go forward with
8 proceeding with this new contract or whether you want to
9 extend the current contract until June. But let's give
10 it until tomorrow morning so everybody has a chance to
11 read through the scripts and think about it a little
12 bit.
13 MR. FISHER: I would also like to make a --
14 I'll make a politically incorrect suggestion.
15 PRESIDENT HUG-ENGLISH: Okay.
16 MR. FISHER: I think it should be made. The
17 board has a lot on their plate for obvious reasons. And
18 I think that what I would certainly like to recommend --
19 and I don't know if it will be acceptable to the board
20 -- you appoint a sub-committee and let the sub-committee
21 hammer out the scripts. Because, in all honesty, if you
22 have a full board that is going to discuss scripts and
23 go into scripts, it's going to make it very, very
24 rugged. And I think you appoint a sub-committee and let
25 that sub-committee pound out the scripts.
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1 PRESIDENT HUG-ENGLISH: I think we did that.
2 I think we have done that. We did that last meeting.
3 And Dr. Montoya and Marlene Kirch have been the people
4 involved in that.
5 And I think that this board just wants to take
6 a look at that and obviously recognizing these are just
7 a first draft but to get an idea of what we are going to
8 go forward with and then we will make a decision on it.
9 MR. FISHER: Thank you for the opportunity.
10 PRESIDENT HUG-ENGLISH: Thank you. Yeah.
11 MR. LEGARZA: If you are going to go to an
12 annual contract with that amount of money, you will have
13 to go to the board of examiners. And if it's going to
14 be sole source, you are going to have to justify sole
15 source.
16 MR. FISHER: We have 20 contracts with the
17 state of Nevada and we will be very comfortable doing
18 that.
19 MR. LEGARZA: My point is you don't get
20 through the board of examiners yesterday. It will take
21 some time to get that done if you decide on an annual
22 contract.
23 MR. FISHER: I understand that.
24 PRESIDENT HUG-ENGLISH: Thank you.
25 Any further comments about this issue? If
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1 not, I think we will bring it up tomorrow for
2 consideration.
3 MR. FISHER: Thank you.
4 PRESIDENT HUG-ENGLISH: Thank you.
5 Agenda item number nine is consideration of
6 the request by Washoe Medical Center for approval of the
7 respiratory care training.
8 MR. LESSLY: I recommend approval.
9 PRESIDENT HUG-ENGLISH: There is a motion to
10 approve the program. All in favor?
11 THE BOARD: Eye.
12 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
13 in favor of the motion, and the motion carries. That
14 was our easiest agenda item yet.
15 Number ten is to -- is a discussion to allow
16 recertification by sub-boards to satisfy the
17 requirements of NAC 630 for licensure eligibility, and
18 we have Lynnette to tell us about that.
19 MS. KROTKE: Good morning. Lynnette Krotke,
20 chief license specialist for the Nevada Medical Board.
21 I heard misinformation this morning and I
22 thought I might start with this. I'm going to be real
23 brief because I know we are running behind.
24 When we opened our laws up to licensure by
25 endorsement, just a little statistics for you, last year
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1 we sent out 745 applications and to date we have sent
2 out 1400 plus applications. So we are processing a lot.
3 I think a nice complement to the opening of pure review
4 for them to meet the tenure requirement would be
5 allowing the recertification by sub-boards.
6 Now, I do have a hand out for you, and you
7 were provided information in your packet. We have a lot
8 of physicians that don't meet the tenure requirement
9 because we do not currently accept subspecialty
10 recertification.
11 I do know of one physician on this board who
12 is currently certified in a subspecialty and that's
13 Dr. Anwar. And he may be able to help me elaborate
14 here. The tests are pretty intense. And I think that,
15 quite honestly, it's stronger than a pure review.
16 That's my opinion.
17 I think it's a lot more involved for the
18 physician, and I think it's a good compliment for what
19 we are trying to do for the physicians to get them
20 through the licensing process and to avoid having so
21 many more boards.
22 DR. BAEPLER: I thought it was always our
23 intent to recognize these. Given the extreme
24 specialization that is required today, this is going to
25 be a common problem for us.
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1 I agree that those are rigorous, but I thought
2 it was always our intent to recognize this as a valid
3 entry point.
4 MS. KROTKE: Not at this time. Just the
5 primary specialty is used as the tenure examination and
6 requirement.
7 DR. BAEPLER: I would certainly move that we
8 accept the subspecialty certification.
9 DR. LUBRITZ: Second.
10 DR. ANJUM: We did use specialty as
11 requirement with the tenure period. We did last time.
12 DR. BAEPLER: Certainly.
13 PRESIDENT HUG-ENGLISH: I think this is trying
14 to clarify that so that it makes it easier for the
15 licensing specialists when they are looking at it that
16 it is clearly the board's intention that they would
17 accept that as an exam.
18 And I think if you look at what has happened
19 over the last five years or so there has been a lot of
20 specialties that have gone to more significant testing.
21 And I think in the past it was sort of loosely
22 associated, and we didn't know as a board how we should
23 value that.
24 But really it is the consistency of exams and
25 kinds of exams that specialties are now giving, I think
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1 make it -- you know, I would agree with what's been
2 stated that we should certainly accept this as criteria
3 to license.
4 DR. ANJUM: We should also keep in mind
5 certain specialties or certain boards don't pertain to
6 that subspecialty and should be kept in mind.
7 I think we had one case last time this person
8 has done some certification in sports and rehab
9 medicine, and he was applying for internal medicine and
10 those things. I think we have one case today where the
11 board certification is in forensics. I don't know how
12 extensive and intensive they are in judging the
13 competency when they consider them for endorsement.
14 MS. KROTKE: If we had an unusual
15 subspecialty, we would most definitely bring it to the
16 board for approval.
17 PRESIDENT HUG-ENGLISH: So there is a motion
18 and a second to approve subspecialty boards. All in
19 favor?
20 THE BOARD: Aye.
21 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
22 in favor of the motion. The motion carries.
23 Thank you, Lynnette.
24 MS. KROTKE: Thank you.
25 DR. BAEPLER: We do have the investigative
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1 committee reports ready.
2 PRESIDENT HUG-ENGLISH: Okay.
3 DR. BAEPLER: For Committee A, I will pass
4 around the copy of the cases that we closed. We had a
5 fairly light load handled by Dr. Titus and myself due to
6 out-of-country absence of Dr. Hunter.
7 We considered 70 cases and authorized filing a
8 formal complaint on 13 of these. These were typically
9 instances where we actually had pure reviews that
10 indicated malpractice, and we felt it necessary to
11 proceed.
12 Many of them do not rise to the level of
13 license revocation, but some intermediate level can be
14 sure that can hopefully be settled.
15 We sent out two more cases for pure review,
16 requested an appearance of two physicians, turned five
17 of the cases back to the investigative staff for
18 additional follow-up investigation, and closed 48 of
19 them. And those 48 are being circulated.
20 PRESIDENT HUG-ENGLISH: Thank you,
21 Dr. Baepler.
22 And, Dr. Lubritz?
23 DR. LUBRITZ: We had a total of 129 cases
24 considered, total cases authorized for filing formal
25 complaints was two.
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1 Total cases authorized for pure review was
2 five.
3 Total cases requested appearance, three.
4 Total cases authorized for further follow-up
5 or investigation, seven.
6 Total cases authorized for closure listed in
7 the IC memo was 112.
8 Total cases listed from the above 84 were
9 civil courts cases.
10 PRESIDENT HUG-ENGLISH: Okay. Thank you.
11 And, again, the information on both of the investigative
12 committee reports will be circulated. So we will wait
13 until you have all had an opportunity to look at those
14 for approval.
15 Again, I just -- I think looking at the number
16 of cases that both investigative committees are looking
17 at, it really is an incredible amount of work and time
18 and effort. And I really appreciate the time that each
19 of the board members puts into that process because it
20 is, you know, very complex and detailed and takes a lot
21 of thoughtful consideration. And so, again, thank you
22 to all the committee members.
23 Okay. Agenda item 11 is discussion of
24 American psychiatric self-assessment exam as it
25 satisfies the requirements for licensure.
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1 And, Dr. Baepler, you were going to talk to us
2 about that.
3 DR. BAEPLER: This is for certification by
4 endorsement. We can forget about using it for the
5 regulations, I assume, for competency evaluation.
6 This one is a hard one to get your arms
7 around. It came to us as a recommendation from the head
8 of the psychiatric association in the state of Nevada,
9 the president of that organization.
10 And you did a better job at finding out about
11 it than I could dig out of the web. I hunted and
12 hunted, and how you discovered this I don't know. I was
13 not able to get as much info.
14 And it's very difficult to separate facts from
15 fiction. You see their educational objectives, for
16 example, and if you read the section on educational
17 objectives, it fulfills everything we can request. But
18 you don't know whether they meet those educational
19 objectives, you see.
20 It's quite easy to state them at one level but
21 meet them at a considerably lower level.
22 My feeling is since it's recommended by the
23 physicians in this specialty already licensed and in
24 good standing, I would be inclined due to the nature of
25 the specialty to go ahead with it.
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1 But don't ask me to rationalize it. We are
2 dealing with psychiatry. So I guess you don't have to
3 rationalize anything, but don't quote that.
4 MS. KROTKE: I think our concern was that it's
5 going through the magazine Focus.
6 DR. BAEPLER: Well, Focus does have some
7 relationship to that profession. In other words, it's a
8 little bit pejorative to just to call it a magazine. It
9 is kind of a professional -- doesn't quite rise to the
10 level of a journal. It's halfway between a journal and
11 a magazine.
12 MS. KROTKE: We just wanted to make sure you
13 were comfortable with it because we were a little
14 nervous.
15 DR. BAEPLER: I'm not comfortable with it. I
16 don't know what the alternative is. It's a very small
17 number of people.
18 MS. KROTKE: That's true. We have pure
19 reviewed three psychiatrists at this point with two more
20 to go. So it is happening more frequently.
21 DR. BAEPLER: But do not let me sway the
22 board. I really don't have much of a foundation to go
23 on.
24 DR. LUBRITZ: Is that pure reviewed for
25 licensure by endorsement?
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1 MS. KROTKE: Correct.
2 DR. LUBRITZ: Okay.
3 PRESIDENT HUG-ENGLISH: So I guess the
4 question is do we need this additional evaluation if we
5 are going to allow them to do pure review to meet the
6 needs?
7 DR. BAEPLER: If they are going to do pure
8 review, we don't need this as well.
9 PRESIDENT HUG-ENGLISH: I mean, if we have
10 pure review as an option, do we need this additional
11 option?
12 DR. BAEPLER: That's the question. The
13 question basically comes down to they can take the specs
14 exam. We recognize a number of exams that they can
15 take. They are proposing that this is the equivalent of
16 one of those exams, and it focuses on their particular
17 specialty.
18 DR. MONTOYA: This could be a module --
19 DR. BAEPLER: Yes.
20 DR. MONTOYA: -- that we haven't seen yet.
21 DR. ANWAR: For whatever it is worth, there is
22 a tremendous shortage of psychiatrists down south. We
23 can't get everybody to the hospitals. And most of them
24 practice out of their offices. We can't get
25 appointments to their offices.
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1 DR. BAEPLER: Then I would move we accept
2 this.
3 PRESIDENT HUG-ENGLISH: Okay.
4 DR. MONTOYA: I would second that.
5 PRESIDENT HUG-ENGLISH: Okay. There is a
6 motion and a second to accept the Focus self-assessment
7 examination as a means to apply for licensure by
8 endorsement for psychiatrists. Any further discussion?
9 DR. TITUS: Before we vote, I would just have
10 to say I'm very uncomfortable with it. I'm not sure
11 there is an acceptable standard in self-assessing
12 sometimes. I'm not -- I'm just not comfortable with it.
13 Actually, I don't have enough information here
14 to have a good feel that I could trust somebody taking
15 this test and then be a competent psychiatrist.
16 DR. BAEPLER: I feel the same way, Dr. Titus.
17 I think my bottom line with me is when the profession
18 itself recommends it, I think they probably know more
19 about it than I do. I believe them to be honorable
20 people, but I do not feel comfortable, of course.
21 DR. LUBRITZ: I guess -- Who is the American
22 Psychiatric Institute?
23 PRESIDENT HUG-ENGLISH: I don't know. I mean,
24 I think that's their national association, I would
25 assume.
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1 DR. LUBRITZ: Again, if we don't know that, I
2 would be reducent to suggesting that we accept it.
3 MS. KROTKE: I don't know if you noticed in
4 the back but this physician also received CMEs for it.
5 So I don't know if that makes a difference.
6 DR. BAEPLER: They do give CMEs for doing
7 this. The editors of Focus are M.D.s which makes it
8 more like a journal. It's not one of these things you
9 sit down in a short period of time. It's quite an
10 involved process you go through. I don't know at what
11 level.
12 DR. LUBRITZ: Could we write to the American
13 Board of Psychiatry and ask them if this is one of their
14 -- if the American Psychiatric Institute is someone who
15 they feel is appropriate to examine their physicians?
16 DR. MONTOYA: They have something in there. I
17 can't think of the page. One of one it says, American
18 Psychiatric Association extended the deadline to receive
19 applications and certification examination of general
20 psychiatry which is the one that we have in here. So
21 American Psychiatric Association has already pretty much
22 endorsed it.
23 DR. BAEPLER: They accepted it.
24 DR. MONTOYA: If that answers your question,
25 about asking them how they feel about it.
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1 MS. KROTKE: It is says the Focus examination
2 may be useful in studying for other examinations such as
3 the general psychiatry recertification examination of
4 the American Board of --
5 DR. TITUS: This doesn't say it's accepted at
6 all.
7 DR. LUBRITZ: I would like to get something
8 from the American Board of Psychiatry that says that
9 this is an upright substitute for their exam.
10 DR. JONES: I agree with that.
11 DR. BAEPLER: It would be a safer way to
12 proceed probably if we could get it.
13 MR. LESSLY: How about a motion to turn the
14 thing down until we approve otherwise.
15 DR. BAEPLER: I will withdraw the motion.
16 DR. TITUS: There is a motion on the floor
17 already.
18 DR. BAEPLER: We can withdraw it or just vote
19 it down.
20 PRESIDENT HUG-ENGLISH: Is the motion
21 withdrawn?
22 DR. BAEPLER: I will withdraw the motion.
23 PRESIDENT HUG-ENGLISH: Is there any motion?
24 DR. LUBRITZ: Yes. I would move that we
25 correspond with the American Board of Psychiatry and ask
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1 the status of the American Psychiatric Institute. Did I
2 give that name correctly? American Psychiatric
3 Association, yes.
4 MR. LESSLY: And we not use the exam until
5 then?
6 DR. LUBRITZ: And we definitely not use it
7 until then.
8 DR. BAEPLER: Yeah.
9 PRESIDENT HUG-ENGLISH: Okay. So will we have
10 an update on that hopefully by our next board meeting
11 then.
12 DR. ANWAR: Can we ask them if they don't
13 approve of this if they have an alternative that they
14 can use.
15 PRESIDENT HUG-ENGLISH: They have a
16 recertification exam.
17 We are not allowing any other specialty to
18 have that besides that. We are saying either they get
19 pure reviewed or they take their recertification exam or
20 the specs exam.
21 We are not coming up with separate exams for
22 each specialty in addition to that.
23 DR. TITUS: I'm concerned if we accepted
24 something like this, all the doctors who don't want to
25 take the American board certification, they are going to
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1 come up with this off-shoot test to take. And we will
2 be doing this with every specialty. We want to make
3 sure we keep our standard high and very clear.
4 PRESIDENT HUG-ENGLISH: Okay. So the motion
5 is to get some more information back. And is there any
6 further discussion? Was there a second?
7 DR. TITUS: Second.
8 PRESIDENT HUG-ENGLISH: All in favor?
9 THE BOARD: Aye.
10 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
11 in favor of the motion. The motion carries.
12 So we will wait at our June meeting and get an
13 update as to what we hear back from the American
14 Psychiatric Board.
15 Okay. I know that we are -- It's lunch time.
16 Can we go through a couple of these other quick ones? I
17 think we are going to be really behind.
18 MR. CLARK: Under 15, reports, we did not
19 discuss status of investigative case load. And I
20 thought it might be interesting to hear from the board
21 -- to hear from the chief investigator and the chief of
22 the investigative division, Doug Cooper, for just a
23 couple minutes to tell the board what the investigators
24 are doing, if that's all right with you.
25 PRESIDENT HUG-ENGLISH: That will be great.
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1 MR. COOPER: Thank you, Tony.
2 I'm Doug Cooper, chief of investigations. I
3 was watching yesterday CNN financial advisor and he said
4 when you speak to a group of people about numbers, the
5 only people who listen are the autistics. I don't know
6 if that's true.
7 I feel that after Dr. Lubritz's presentation
8 on why we would possibly need two investigators that you
9 might have already heard some of this stuff. Thank you
10 very much for approving that staffing increase. It's
11 greatly appreciated.
12 Right now just before we approve the closure
13 of the cases from the two ICs, we had 689 open
14 investigations.
15 With that closure, we are down to 636
16 investigations.
17 Luckily, we have 97 of that 636 held in
18 abeyance because we can't handle the workload right now.
19 Those cases have been selected because they look and
20 appear to be minor cases from the court filings.
21 Our average is 108 per investigator right now.
22 Taking those numbers with two new persons that would be
23 72 per investigator which I think we could handle
24 easily.
25 A lot of these cases do get resolved quickly
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1 because they are duplicates of cases that we have
2 already done. And by that I mean we could have a case
3 where we investigated a case based on a citizen
4 complaint, and then we get the case to us again as a
5 court filing.
6 We do list those because I want to be able to
7 tell the board what happened to every civil court filing
8 in the state of Nevada, if we are ever asked.
9 Yes, we did look at it. It was a duplicate.
10 We didn't investigate it for lack of merit. It was
11 dismissed. We did investigate it.
12 Aside from actually doing the investigation
13 and preparing it for the investigative committees the
14 biggest time consuming effort we put out is the
15 preparation for pure reviews.
16 And I think Steve wanted to talk about pure
17 reviews in a minute and the problems that we have.
18 In 2002 we had an average pure review work
19 load of about 30 to 40 pure reviews. As of 1, July we
20 had an average of 49 pure reviews pending to be done
21 July 2003. Five months later, in December, we had 80.
22 Now as we sit here today, we have 130 pure
23 reviews that need to be conducted by the good doctors of
24 the state of Nevada based on investigations that we are
25 doing.
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1 This is not including the pure reviews that
2 are done for licensing. That's a separate group. What
3 we did do, though, with Lynnette's help we have Pamela
4 Castagnola who is an investigator on the investigative
5 staff working and getting the pure reviews for licensing
6 purposes done for the licensing sections. And also her
7 and I are handling getting pure reviews for the
8 investigations.
9 The reason we did that was because we wanted
10 to be able to control all of the doctors that were being
11 called and asked to do pure reviews. We couldn't have
12 five investigators in licensing calling people around
13 the state. We would make someone angry very quickly, I
14 believe.
15 So there are 59 currently pure reviews pending
16 completion. In other words, they are out in the field
17 of 103 and we have a backup of 44 ready to go.
18 I know that some people have said, Well, the
19 civil court filings which has greatly increased our work
20 load will probably level off. And I have done some
21 research, and I think that leveling off has already
22 happened.
23 There is for 2003 an average of 61 civil court
24 filings on medical torts in the state of Nevada. By
25 doing an actual count of how many of those included a
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1 medical doctor or a medical issue and not a hospital or
2 DO, there seems to be an average of about 25 that are
3 M.D.s each month.
4 Now that doesn't sound like too many, but 50
5 or 60 percent of those include multiple physicians.
6 It's not just one doctor being sued.
7 If we get a civil court filing where a doctor
8 is being sued and three other M.D.s are included, we
9 have to open an investigative file with every one of
10 those physicians and investigate those too. So that
11 does cause a jump in the numbers, but it represents real
12 work that we have to do.
13 I think with the addition of additional
14 investigators I believe that -- and the leveling off of
15 the Clark County and Washoe County civil court cases, I
16 think this time next year we will probably be running
17 about 40 to 50 cases per investigator. That's our goal
18 and hopefully we will be able to pull that off.
19 DR. BAEPLER: I have one comment. I'm a
20 little bit uncomfortable with the way in which we handle
21 the pure review process now from the investigative
22 committee perspective. Namely, it's not the committee
23 that decides to send something out for pure review
24 unless we have a case that we are discussing that hasn't
25 been pure reviewed and we say, Gee, we need an expert
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1 opinion.
2 The decision might be made by Dr. Barnet,
3 could be made by staff. I'm not sure where the focal
4 point of that is. But as soon as you send something out
5 to pure review before the committee has even looked at
6 the case, you tie the hand to the committee.
7 Doctors are very reluctant to give a pure
8 review where they use the word malpractice. This was
9 malpractice. In this last meeting we had several.
10 Now the committee might sit there and say,
11 Gee, we just don't like this, but we ought to perhaps
12 file something here to take some kind of disciplinary
13 action. But the legal staff very correctly says, I
14 can't pursue a case when your own expert has told you
15 it's not malpractice, you know. So we aggregate the
16 whole function of the committee every time we send it
17 out to pure review, in my opinion.
18 I think there are cases where we don't have to
19 use the word malpractice that we could pursue, if it
20 hadn't been pure reviewed. And increasingly I think
21 everybody on the IC committee when you get that good
22 pure review back you just know well we can't touch this.
23 MR. COOPER: I hope you didn't mean to think
24 that we are blaming the pure review increase on you.
25 DR. BAEPLER: No. We might want to help solve
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1 the problem by being a little more judicious as to which
2 ones we want pure reviewed.
3 MR. COOPER: These numbers represent a portion
4 of the increase in case load.
5 DR. BAEPLER: Sure they would. Where is the
6 decision made to send it out to a pure review?
7 MR. LEGARZA: By Dr. Barnet and/or the --
8 MR. QUINN: Counsel is involved in that
9 decision.
10 MR. LEGARZA: I'm sorry. Yeah, sure.
11 MR. QUINN: What happens is a case comes in,
12 it's investigated. The investigation results in the
13 factual information. Often times it's medical records
14 and a response.
15 When the medical dental screening panel was in
16 affect it was very beneficial to us because we would get
17 prepared medical records as well as our expert opinions
18 coming in on both sides of the case.
19 But if that's not the case, we will get
20 medical records. Those are generally the facts of the
21 case.
22 Dr. Barnet will look at them. If he
23 determines initially in his judgment that there is not a
24 reasonable basis to proceed, he will recommend closure
25 at that point. That's where that closure
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1 recommendation --
2 DR. BAEPLER: I know that.
3 MR. QUINN: If he determines there is a
4 reasonable basis to proceed, depending on what that
5 basis is, he will refer it to counsel for consult or he
6 will just recommend a pure review at that stage.
7 DR. LUBRITZ: But you don't get the pure
8 review until it comes to the IC, is that correct?
9 MR. QUINN: No. That's not correct.
10 DR. BAEPLER: We have no hands in it.
11 DR. LUBRITZ: We would prefer that we will, at
12 least, see it in the IC to determine if we agree that it
13 should be pure reviewed.
14 DR. BAEPLER: That could slow it down a lot.
15 MR. QUINN: It will slow it down.
16 DR. LUBRITZ: What Dr. Baepler is saying is
17 regardless of what we as the IC may feel, once you get
18 something that says this is not malpractice, then we
19 just soon throw the case away.
20 MR. LEGARZA: How are you going to prove it is
21 not malpractice, Doctor, without a pure review?
22 DR. LUBRITZ: We will get pure review once we
23 have agreed with counsel and with Dr. Barnet concerning
24 that.
25 MR. LEGARZA: That may not change the results
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1 of a pure review.
2 DR. LUBRITZ: I didn't say it would change the
3 result. It may cut down on some of the pure reviews.
4 MR. LEGARZA: That is correct. It may.
5 DR. LUBRITZ: That's our point. If we are
6 having difficulty in getting pure reviewers, this may be
7 a way to cut down on some. I don't know that it would,
8 but when it's done, there is no sense in going back and
9 saying we didn't need it. It's done already.
10 DR. TITUS: Right. One of the issues for the
11 IC committee is if we are waiting for all these pure
12 reviews to come back before the IC sees them some of
13 them maybe we wouldn't have even sent out for pure
14 review. I don't think it's going to extend the time
15 line because the time is already set. They can get to
16 the committee sooner if we are not waiting for a pure
17 review. And then we will see if they warrant a pure
18 review and let that be based on the IC committees as
19 opposed to Dr. Barnet before it gets to IC.
20 In actuality, I think the time spent will be
21 less than the opposite.
22 PRESIDENT HUG-ENGLISH: Isn't that one of the
23 reasons we have hired Dr. Barnet, though, is to actually
24 make that determination?
25 MR. COOPER: Usually the cases that Dr. Barnet
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1 refers out to pure review before the IC are usually
2 pretty complicated.
3 He is seeking the advice of someone because of
4 the complexity of the case. He can't decide. He is
5 thinking in his best judgment that in order for the
6 investigative committee to decide, a pure review
7 probably should be done in order to present the case
8 properly to the IC.
9 DR. ANJUM: When he requests pure review, does
10 he look at pure review before it goes to the
11 investigative committee?
12 MR. COOPER: When the pure review comes back,
13 Dr. Barnet will look at it and comment on it. He will
14 do another medical review of how that pure review
15 changes the case and that goes into the packet that you
16 receive.
17 DR. ANJUM: If the case goes to the IC
18 committee anyway after pure review, then the
19 investigative committee reviews even before that, it
20 will go to IC committee anyway. Why wait for the pure
21 review? Maybe we can eliminate some of pure review.
22 Does he eliminate the case after having the pure review?
23 MR. COOPER: In some cases that might happen
24 where the investigative committee might say, Well, we
25 don't really need a pure review. My experience would
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1 say that wouldn't happen very often. At that point it
2 could add time. If that case came back two days after
3 an IC, you could have potentially three months before
4 that case goes to the IC.
5 DR. BAEPLER: We have held an IC meeting
6 totally independent of the timing of the board meetings.
7 You know, you can hold an IC meeting any time.
8 MR. COOPER: Would we do that for one pure
9 review that came in?
10 DR. MONTOYA: I would like to mention that
11 Dr. Barnet streamlines the system a lot. I never see a
12 pure review that didn't need to be done. He streamlines
13 it. We already have it right there.
14 I trust his judgment in what he thinks that
15 needs to go out for pure review. He does a good job.
16 He doesn't frivolously say pure review
17 everything. It's a considered decision that he makes as
18 to what gets pure reviewed.
19 I believe he streamlines the system, and he
20 gets the stuff to us quicker. And I don't think we need
21 to add another layer saying maybe this would have gotten
22 a pure review.
23 MR. COOPER: The goal really is to have
24 everything in there that possibly needs to be in there
25 so the IC can make an intelligent decision about what
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1 they want to do with that doctor in that set of
2 circumstances.
3 And in those cases where we already know it's
4 going to be pretty complex to have that already done, it
5 helps us meeting that goal.
6 DR. LUBRITZ: I withdraw my suggestion.
7 PRESIDENT HUG-ENGLISH: Okay. And is there
8 anything else, Doug, you wanted to add?
9 MR. COOPER: No.
10 PRESIDENT HUG-ENGLISH: Thank you for that
11 update. It sounds like we are keeping you busy.
12 MR. QUINN: Doug suggested and it might be an
13 opportune time to take it now -- my comments regarding
14 the situation of pure reviews. And I was going to put
15 it in my legal report, but I will talk now.
16 Do the number of cases -- obviously there is a
17 serious burden in attempting to get pure reviewers.
18 Last year there were 105 cases sent out for pure review.
19 Of 67 of those, over 60 percent came back with
20 no malpractice.
21 Less than 25 percent came back with
22 malpractice and two undecided. One unfinished.
23 In addition to the difficulty of getting pure
24 reviewers, I'm not sure, but it might be that we are
25 experiencing a situation where there is a reluctance of
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1 the pure reviewers to find malpractice in cases.
2 Generally we use in-state physicians. My
3 experience in the legal profession just practicing law
4 is that there can be a fear of professional ostracism
5 and also perhaps uninformed, misinformed belief that
6 finding malpractice contributes to the quote malpractice
7 crisis closed quote which is not the case.
8 The malpractice crisis is a situation where it
9 is like taxes. The malpractice insurance premiums are
10 not moving down.
11 But it may be on occasion or have to out of
12 necessity start looking out of state for pure reviewers.
13 At least in the case of some specialties or
14 subspecialties where the community of practitioners in
15 that specialty or subspecialty in Nevada is relatively
16 small.
17 DR. BAEPLER: It raises the cost a whole lot.
18 DR. ANWAR: I have a comment. And I think
19 those are wonderful suggestions in case we still feel
20 that we need some help that we don't have expertise in
21 the State that we should call for outside help.
22 But beware of professional physicians who do
23 that -- who do that as a component of their professional
24 expertise just to provide adverse opinions.
25 And there is a whole list of that for United
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1 States that are called upon by the appropriate people
2 for help and who need help.
3 So when we are doing due diligence what we are
4 trying to look at as objective and detailed information
5 to make our determination to the end that we want to
6 achieve protection of our public. But in due
7 deliberations, we are not necessarily looking for
8 problems. We want to look at all the information that
9 is there and be able to arrive at that conclusion that
10 would help us make those determinations.
11 MR. QUINN: If I may respond to that. I am --
12 I have had a lot of experience practicing. And I
13 realize my function here is a function as a public
14 entity. And as such, I am not driven by a result. On
15 the other hand, there is a benefit to those who see this
16 as a professional basis because they are not only
17 experts in the professional field, they know how to deal
18 with it in the litigation field as forensics.
19 I would always, always ask that -- I would
20 never indicate what result I wanted. I would always ask
21 whatever result I get is the one that you genuinely
22 believe to be correct.
23 As a public entity, we don't have to be result
24 oriented in that respect. We just need to do the right
25 thing.
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1 PRESIDENT HUG-ENGLISH: Okay. Any further
2 comments about the pure review process?
3 Can I have a motion? I think everybody has
4 had a chance to look at the investigative reports. Can
5 I have a motion to approve the cases that have been
6 recommended for closure?
7 DR. MONTOYA: So moved.
8 DR. ANWAR: Second.
9 PRESIDENT HUG-ENGLISH: All in favor?
10 THE BOARD: Aye.
11 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
12 in favor of the motion. Motion carries.
13 Do you need to take a break?
14 MR. CLARK: A note of caution, we agreed to
15 accommodate Dr. Torch to come in at 1:00, and we weren't
16 going to start the other personal appointments until
17 later. And the reason is, he was leaving on vacation.
18 PRESIDENT HUG-ENGLISH: Okay.
19 MR. CLARK: He has put off his flight to do
20 that, and he is attempting to collaborate with an
21 advanced nursing practitioner who has been disciplined
22 by the nursing board.
23 PRESIDENT HUG-ENGLISH: We have to wait until
24 1:00? He is not here until 1:00?
25 MR. CLARK: He will be here at 1:00. If you
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1 want to have lunch before then you have to get back --
2 PRESIDENT HUG-ENGLISH: So I think we need to
3 recess and give everybody a break.
4 DR. TITUS: There is a big pause after he is
5 here, though.
6 PRESIDENT HUG-ENGLISH: So what I'm suggesting
7 is we take this half hour, have our lunch, come back and
8 then proceed with the rest of the agenda.
9 (Recess was taken.)
10 PRESIDENT HUG-ENGLISH: I'm going to call this
11 meeting back to order. I know we have had a very brief
12 lunch, but if we can all reconvene to address
13 Dr. Torch's letter that he sent to the board requesting
14 consideration to collaborate with an advanced nurse
15 practitioner that had been disciplined.
16 And Dr. Torch is with us today.
17 (Whereupon the proceedings went into closed session.)
18 MR. QUINN: Item number 18 is present. That's
19 adjudication. No, it's not. This is a -- now is this a
20 closed-session issue? This is a discussion --
21 MR. LESSLY: No, it's not closed.
22 DR. TITUS: We go up to the regular thing.
23 PRESIDENT HUG-ENGLISH: That's what I was
24 thinking.
25 MR. QUINN: Do you want to call that in?
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1 PRESIDENT HUG-ENGLISH: No. Was that for a
2 particular time?
3 MR. QUINN: One-fifteen.
4 PRESIDENT HUG-ENGLISH: Oh, it was.
5 MR. QUINN: And he is here.
6 PRESIDENT HUG-ENGLISH: Okay. If we had a
7 time. That's okay.
8 Well, then we will move to agenda item 18
9 which is consideration of proposal of settlement in the
10 matter of Elliott Schmerler.
11 DR. BAEPLER: Is this where only the
12 adjudicating members could vote?
13 DR. MONTOYA: Or even should be here.
14 MR. QUINN: I don't think it's a problem with
15 a non-adjudicating member being present.
16 MR. CLARK: As long as they don't vote.
17 MR. QUINN: Possibly the only adjudicating
18 members are the ones who should decide since it is an
19 issue of settlement of that case that they adjudicate.
20 PRESIDENT HUG-ENGLISH: Correct me, this would
21 be an open session? We are not -- This is not a closed
22 session issue.
23 And do we have Dr. Schmerler here?
24 DR. BAEPLER: Yes.
25 DR. JONES: We didn't get anything on that.
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1 Do we need to have anything?
2 MR. CLARK: No. I don't think you need
3 anything on it. I will give you a quick overview, and
4 you can decide what you are going to do.
5 DR. JONES: Okay.
6 DR. LUBRITZ: I'd like to know a little bit
7 before. Don't we --
8 DR. TITUS: I move we go into closed session.
9 MR. LEGARZA: You never had one of these.
10 DR. LUBRITZ: Bring him on.
11 DR. TITUS: We are open still?
12 DR. JONES: You are.
13 PRESIDENT HUG-ENGLISH: Tony, why don't you go
14 ahead and start and let us know what this is about.
15 MR. CLARK: The board had a hearing, revoked
16 Dr. Schmerler's license.
17 Prior to the revocation he was offered an
18 opportunity to surrender his license while under
19 investigation, and he turned that down.
20 After the revocation he sought judicial review
21 before the Second Judicial District Court and lost. He
22 filed an appeal to the Nevada Supreme Court.
23 The Nevada Supreme Court has rules which
24 require in all civil cases be subject to mediation
25 before presentation to the court to see if they can get
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1 them settled ahead of time so that the supreme court
2 does not have to hear those cases.
3 At the mediation that took place with the
4 supreme court's mediator, Dr. Schmerler through his
5 counsel, made an offer to surrender his license while
6 under investigation with prejudice, meaning he would
7 never attempt to be relicensed for practice in the state
8 of Nevada again.
9 Mr. Quinn, deputy general counsel, and I were
10 not in favor of that. But since the mediator told us
11 that we had to go through mediation and present this to
12 the board, we told them we would present it to the board
13 for the board's determination.
14 Mr. Quinn feels that the case is strong and
15 would prefer to go forward with it. I don't recommend
16 that you accept the mediation offer, and I'm real
17 concerned that what we get into is another D'Ambrosio
18 situation.
19 But we have to present to the board -- we had
20 to present to the board the opportunity to consider the
21 mediator offer to withdraw the revocation and accept a
22 surrender of license while under investigation with the
23 understanding that Dr. Schmerler would not attempt to
24 practice in Nevada again.
25 And the adjudicating members --
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1 PRESIDENT HUG-ENGLISH: Tony, can you just
2 review the reason for the revocation?
3 MR. QUINN: Okay. Dr. Schmerler was convicted
4 of tax evasion. And I am correct, the board -- he was
5 charged with commission of a felony and convicted of an
6 offense involving moral turpitude.
7 And the disciplinary action was on the basis
8 of a finding of -- I believe finding of guilt on both
9 aspects of it.
10 He and his counsel are present here. Is that
11 accurate, counsel?
12 DR. SCHMERLER'S COUNSEL: Just to clarify, he
13 was convicted of tax evasion. There was no conviction
14 as to an offense involving moral turpitude.
15 That is something he was charged with by the
16 board, and what he took to hearing with the board.
17 MR. QUINN: That's what the board convicted
18 him of.
19 DR. SCHMERLER'S COUNSEL: Just to clarify, the
20 Federal Court did not --
21 MR. QUINN: There is no federal charge.
22 The board charges against him were -- the
23 grounds for disciplinary action were conviction of a
24 felony and also a second count of conviction of an
25 offense involving moral turpitude. Those were the
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1 charges before the board, and the board found
2 Dr. Schmerler guilty on both counts, correct?
3 DR. SCHMERLER'S COUNSEL: That's correct.
4 MR. QUINN: And then the board's disciplinary
5 action that they decided upon was revocation.
6 DR. SCHMERLER'S COUNSEL: That's correct.
7 MR. QUINN: And it was that action that he is
8 basically on appeal to the supreme court now because you
9 took judicial review at the district court level and
10 lost at the district court level. And now you are
11 appealing to the supreme court the board's disciplinary
12 action.
13 DR. SCHMERLER'S COUNSEL: That's correct.
14 MR. QUINN: That's correct.
15 PRESIDENT HUG-ENGLISH: Thank you for that
16 summary.
17 So at this time we can have discussion. And,
18 again, it's just the adjudicating members who are
19 myself, Dr. Jones, Dr. Lubritz, Marlene Kirch,
20 Dr. Titus, Dr. Anjum, and Dr. Anwar who are the
21 adjudicators. So is there any discussion by the
22 adjudicating members on this issue?
23 MS. KIRCH: If we accept this agreement, what
24 type of reporting is done if we accept the surrender?
25 PRESIDENT HUG-ENGLISH: It's reported just as
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1 that. And I think the issue, as I see it, is that
2 although we consider a surrender of license under
3 investigation the same as we would a revocation, it's
4 certainly been brought to our attention that other
5 states do not do the same.
6 And I think we have had a previous case that
7 has been illustrated very aptly for this board. And so
8 I certainly for myself am not in favor for accepting
9 this mediation because I think it was the intent of this
10 board to revoke the license. That's what we made the
11 decision. And to change the status of that, I think may
12 not be interpreted the same way we interpret it in other
13 states.
14 Charolette?
15 MS. BIBLE: In fact, this just came across in
16 our materials we had. There is a case right on point in
17 Washington State of Supreme Court that upheld a medical
18 board's decision to revoke a physician's license who was
19 convicted of tax fraud.
20 And the reasoning I think that might help you
21 is it is stated, The daily practice of medicine
22 concerned life and death consequences to members of the
23 public. They have an understandable interest in the
24 maintenance of sound standards of conduct by medical
25 practitioners.
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1 The public has a right to expect the highest
2 degree of trustworthiness of the members of the medical
3 profession. We believe there is a rational connection
4 between income tax fraud and ones fitness of character
5 or trustworthiness to practice medicine so that the
6 legislature can properly make fraudulent conduct or
7 substance abuse were inferences for grounds of revoking
8 or suspending such licenses. It has been upheld, and we
9 certainly support other states.
10 PRESIDENT HUG-ENGLISH: That's good
11 information to have.
12 DR. ANJUM: This option was offered to
13 Dr. Schmerler before the license was revoked?
14 DR. SCHMERLER: Yes, it was.
15 DR. ANJUM: Well, he was given this option
16 before.
17 DR. SCHMERLER: I didn't think my license was
18 going to be revoked so I didn't accept it. I didn't do
19 it. I didn't surrender my license.
20 But Mr. Legarza told my attorney that I should
21 surrender my license, and I wish I would have taken his
22 advice because at present this is a death sentence for
23 me. I can't practice in any of the 50 states. I have
24 checked. No one will even hear my application.
25 If it's a self-surrender, at least, I would
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1 have the opportunity to practice in another state.
2 DR. TITUS: Moving from our state to another
3 state is one of the things we want to discourage.
4 I think if you have been convicted of an event
5 that we feel that you should not be practicing in our
6 state, I'm not sure we would want to be in a position
7 that you would just move to another state.
8 DR. SCHMERLER: It's not that easy. I have to
9 go before the board in another state. And I'm currently
10 trying to practice in Arizona. And their statute says
11 if you have a felony, it cannot be used to remove your
12 license unless it involves the practice of the trade
13 within the state.
14 There was a practicing cardiologist at Nelson
15 Prison camp who was serving time for the exact same
16 charge, exact same conviction. He had two licenses.
17 One was in Arizona and one was in Pennsylvania. Both
18 cases he received a letter of reprimand. His license
19 wasn't suspended or revoked.
20 So I appreciate your stand. And my feeling is
21 that if that's your decision, that should apply to the
22 boarders of Nevada. And it shouldn't govern me with
23 regards to the other states.
24 The other state boards should have the same
25 opportunities that you have to make their own decisions.
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1 PRESIDENT HUG-ENGLISH: As they do. We are
2 not making adjustment for what any other state will
3 decide.
4 I think what this board has to decide is
5 whether the decision we made is an appropriate one for
6 our state. And we can't make decisions for other
7 states.
8 But I think certainly the process that we went
9 through in coming to this decision was one that you were
10 offered that initial choice. You refused. We went
11 forward, and we revoked your license.
12 And, I guess, the decision that we need to
13 make as a board today is whether we want to change that
14 decision that we initially made.
15 DR. ANJUM: I have one more comment to make.
16 Every crime has a punishment, and it is rightfully done
17 so.
18 Every punishment has a limit and duration and
19 extent.
20 If you commit a murder, you go to jail for
21 life or for 25 years.
22 You commit a crime, there should be some limit
23 on that. My feeling is, yes, he did not take the option
24 to surrender, but is that a crime bad enough that should
25 be barred from practicing medicine forever? There's my
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1 concern.
2 MR. LEGARZA: This wasn't Dr. Schmerler's
3 first experience with the Nevada State Board of Medical
4 Examiners.
5 Dr. Schmerler has a prior conviction in
6 violation of the medical practice act in the state of
7 Nevada wherein Dr. Schmerler was performing lipo-suction
8 and substantially hurt some patients as well as engaged
9 in conduct intending to deceive by having certain
10 documents executed by the patient under certain
11 representations that his procedure was $15,000 but he
12 would give them a $10,000 reduction in the fee if they
13 would agree not to sue him. So he has a prior
14 experience with this board as well.
15 I handled that case. I prosecuted that case,
16 and I prosecuted the second case. And he was given the
17 option, which I felt was beneficial to him at the time
18 to surrender his license while under investigation.
19 Nothing less was acceptable to the investigative
20 committee that authorized the filing of the formal
21 complaint.
22 He saw fit to challenge it, and this board saw
23 fit to revoke his license as a result of that.
24 DR. ANJUM: That is all true and correct, and
25 I understand. But any crime should have a limit on the
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1 punishment.
2 PRESIDENT HUG-ENGLISH: He can reapply at any
3 time. Revocation is a revocation. It doesn't mean that
4 he can't at some point submit another application in
5 this state or another. It's difficult, but --
6 DR. ANJUM: The status of most of the states
7 is such that, like he said, wouldn't even entertain the
8 application.
9 MR. LEGARZA: You don't have a right to
10 practice medicine, Doctor. It's a privilege. The
11 practice of medicine is a privilege.
12 He is not precluded from making a living. He
13 is precluded of making a living at the present time in
14 medicine in the state of Nevada.
15 DR. SCHMERLER: I made my choice. I paid my
16 debt to society. I went to prison. I served my time.
17 I have been without income. I have been
18 without a license. I have four children. I have
19 studied all my life to become a physician.
20 And I think the doctor's point -- isn't there
21 a limit as to the punishment? Shouldn't the punishment
22 fit the crime? And I think that's the point that is
23 trying to be made.
24 MR. LEGARZA: I understand what the doctor is
25 saying, and I respect the doctor's position.
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1 DR. SCHMERLER'S COUNSEL: May I speak please?
2 One of the things to consider is the purpose of the
3 board is not to punish. And certainly what I'm hearing
4 now is, Hey, we gave him a chance to surrender. So too
5 bad. We are not going to give you that opportunity.
6 Had he accepted that opportunity, he would have had the
7 same opportunity you don't want him to have now.
8 But because he didn't accept that at that time
9 now he is basically punished for defending against a
10 claim that we will continue to move forward at the
11 supreme court.
12 PRESIDENT HUG-ENGLISH: I disagree with you a
13 little bit. I think when the matter came before the
14 board, the board made the decision to revoke. What
15 Mr. Legarza is saying that at the time before it came to
16 the board, he had offered a stipulation for settlement
17 which this board may or may not have accepted.
18 And when the case was brought before this
19 board, the decision of this board was to revoke his
20 license.
21 And it isn't because he chose not to surrender
22 his license. It was based on the evidence and the
23 materials submitted to this board. And the decision was
24 made based on that evidentiary proceeding, not what had
25 come before.
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1 And it was not done as a punishment for him
2 not accepting the settlement.
3 DR. SCHMERLER'S COUNSEL: My point is
4 generally the board would accept the recommendation by
5 its counsel. And if counsel would come ahead and we'll
6 accept his surrender, it was declined. But my point
7 really is that the purpose is to instill public
8 confidence. And if you want to instill public
9 confidence, certainly he has paid for his crime and that
10 payment as the doctor mentioned should have its
11 limitations. It should not be ongoing.
12 And the purpose of this board is certainly not
13 to punish or to continue to punish.
14 The crimes for which he was convicted have
15 nothing to do with patient care. So that is certainly
16 not an issue that the board should be considering in
17 terms of should he stop practicing indefinitely.
18 DR. TITUS: I have a question.
19 MS. BIBLE: I would disagree with your
20 conclusions that it doesn't affect patient care because
21 trustworthiness, integrity, those are characteristics
22 that are important in a physician.
23 And it does go to the ability to provide
24 quality care to patients. And it is this board's
25 obligation to protect the public. And it was their
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1 determination that that crime should be penalized by the
2 revocation.
3 And you did get an opportunity to settle. And
4 settling, I think, is so it avoids having to go through
5 hearing, to be a method of economizing resources and
6 give him that opportunity.
7 He didn't take that. So he took his chance.
8 And he came to the board. And then he saw that the
9 penalty of the board imposed was greater in a worse
10 result than if had he taken the settlement.
11 But this is a regulatory board. Their duty is
12 to protect the public and not continue negotiating with
13 respondents long after the matter has been heard and
14 adjudicated by them.
15 DR. SCHMERLER'S COUNSEL: Understandable, but
16 the Nevada Supreme Court has allowed for these very
17 mechanisms in these very types of cases. And in
18 previous cases the Nevada Supreme Court has ruled that
19 tax evasion does not necessarily amount to an offense of
20 moral turpitude. And this has just been a conclusion.
21 Okay. There is a conviction and then automatically you
22 have got moral turpitude. That's not the way the Nevada
23 Supreme Court has looked at it.
24 They have allowed attorneys to continue to
25 practice and they have allowed doctors to continue to
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1 practice under those circumstances.
2 DR. TITUS: When was the last time, Doctor,
3 you practiced medicine?
4 DR. SCHMERLER: December of '02.
5 DR. TITUS: So you have not practiced medicine
6 for a year and a half?
7 DR. SCHMERLER: My prison sentence was from
8 January 6 to February 6 -- January 6, '03 to February
9 '06 -- '04.
10 DR. TITUS: What have you done to maintain
11 your currency in --
12 DR. SCHMERLER: Actually, I studied throughout
13 my term. And I have taken several medical courses
14 through the prison. And, in fact, I just completed 60
15 hours of CMEs.
16 But my point is really this: I have served my
17 time. I have been penalized pretty much as severe as
18 anyone can be penalized.
19 I made a really stupid, horrible mistake. I'm
20 eternally sorry for that. It will never happen again.
21 I practiced in Nevada for almost 18 years and
22 with this and those two lipo-suction cases which is -- I
23 will be happy to talk about, are the only two instances
24 in the 18 years. So I think you have to take into
25 account my whole track record in Nevada.
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1 I have seen thousands of patients over that
2 period of time. And this is the only trouble I have
3 ever been in. This is my first offense. I have never
4 been in trouble in my life.
5 So I would plead with you to please allow me
6 to have a second chance.
7 Don't penalize me for life, because I can
8 assure you I have researched having a revocation in the
9 United States it's impossible to go to another -- to
10 ever practice again. And you say, Well, I can just
11 reapply to this board. But the fact is I still believe
12 that I would have an unfavorable outcome based on what
13 I'm hearing today.
14 MR. LEGARZA: In order to accept this doctor's
15 argument, one of the things that, I guess, you have to
16 consider is, I guess, you are not supposed to revoke
17 anyone.
18 I guess you are not supposed to revoke a
19 license. I'm not arguing with you, Doctor. I'm not
20 talking to you.
21 PRESIDENT HUG-ENGLISH: Doctor, please allow
22 counsel to speak.
23 MR. LEGARZA: The board has decided to revoke
24 this doctor's license. I guess the argument must be you
25 shouldn't revoke someone's license.
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1 You have made that decision, and it's very
2 proper for you to revoke a license.
3 PRESIDENT HUG-ENGLISH: Charlotte?
4 MS. BIBLE: I didn't have all the materials to
5 refresh my memory, but this is not just a simple failure
6 to pay tax, a tax evasion case.
7 There was a whole scheme and course of conduct
8 on the part of this doctor in filing false bankruptcy,
9 court documents, creating a corporation, off-shore
10 corporations, hide money and to have an avenue for tax
11 deductions. There is a whole -- it's not just one
12 instance of failure to pay taxes. It was a whole scheme
13 of things to hide assets and to prevent his wife from --
14 and showing income so his wife couldn't have access to
15 those.
16 DR. SCHMERLER: Excuse me. That is just not
17 true. I really don't want to get in a situation where
18 I'm arguing, but that's really not true.
19 I didn't hide one penny overseas. Not one
20 penny is left in the bank. The whole purpose was not to
21 hide money at all.
22 The stupid thing I did was not correctly
23 categorize my tax deductions. The problem I had was the
24 corporate deductions. There was nothing illegal about
25 the corporation. There was no money hidden. Every
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1 penny was reported accurately to the IRS.
2 PRESIDENT HUG-ENGLISH: I really have a
3 problem with reviewing details of the hearing, because
4 we don't have that in front of us.
5 Again, really what we are here today is to
6 determine whether or not this board feels that we should
7 change our determination in what we did in revoking
8 Dr. Schmerler's license. And that is really the only
9 purpose right now that we have is to determine whether
10 we want to change the revocation to a suspension.
11 If we uphold the -- I'm sorry. Surrender
12 under investigation.
13 If we uphold the revocation, Dr. Schmerler
14 still has the opportunity to continue his appeal through
15 the supreme court.
16 This is a mediation process that we have been
17 asked to look at. If we say no, Dr. Schmerler can
18 certainly proceed with his appeal up to the next step.
19 So I think that's where we are with this.
20 DR. SCHMERLER: The problem that I face in
21 that situation is it's a very lengthy process. It can
22 take a year or two from today, and I have already been
23 out of work for over a year. So that's really --
24 DR. LUBRITZ: Are we ready to accept a motion?
25 PRESIDENT HUG-ENGLISH: Yes.
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1 DR. LUBRITZ: I would make a motion that we --
2 I want to word this properly -- that we maintain the
3 original position of the board in revoking the license.
4 PRESIDENT HUG-ENGLISH: There is a motion to
5 uphold the original position of the board and the
6 revocation of Dr. Schmerler's license. Is there a
7 second?
8 MS. KIRCH: Second.
9 MR. QUINN: If I may, Madam President, just
10 for purposes of technical accuracy. What we are really
11 doing is deciding whether to accept or reject the
12 settlement proposal in the supreme court mediation. So
13 that's what that motion is. The motion is to reject the
14 settlement.
15 DR. LUBRITZ: I'll accept that.
16 PRESIDENT HUG-ENGLISH: Okay. So just so that
17 we are all understanding this motion that is on the
18 table is to reject the settlement mediation offer as
19 presented.
20 Now I'm going to call role call vote for this.
21 These are just the adjudicating members. Dr. Jones?
22 DR. JONES: Yes.
23 PRESIDENT HUG-ENGLISH: Dr. Lubritz?
24 DR. LUBRITZ: Yes.
25 PRESIDENT HUG-ENGLISH: Dr. Titus?
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1 DR. TITUS: Yes.
2 PRESIDENT HUG-ENGLISH: Marlene Kirch?
3 MS. KIRCH: Yes.
4 PRESIDENT HUG-ENGLISH: Dr. Anjum?
5 DR. ANJUM: No.
6 PRESIDENT HUG-ENGLISH: Dr. Anwar.
7 DR. ANWAR: Yes.
8 PRESIDENT HUG-ENGLISH: And I vote in favor of
9 the motion. Motion carries.
10 So the decision of this board has been upheld,
11 and we reject the mediation offer at this time.
12 DR. SCHMERLER: Can I ask you a question?
13 PRESIDENT HUG-ENGLISH: Yes.
14 DR. SCHMERLER: Is there any way for me to get
15 relicensed in Nevada by reapplying?
16 PRESIDENT HUG-ENGLISH: I think that would be
17 unwise on your part at this time. You certainly have
18 the option to submit a new application, but I would not
19 advise you to do that at this time.
20 MR. SCHMERLER: Why is that?
21 PRESIDENT HUG-ENGLISH: I don't think from
22 what you have just heard from this board today that
23 there is going to be an appetite to accept a new
24 application from you since we just upheld the
25 revocation.
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1 DR. SCHMERLER: I'm not talking today, but at
2 a later date.
3 PRESIDENT HUG-ENGLISH: At a later date?
4 Certainly. You have an opportunity to submit an
5 application.
6 DR. SCHMERLER: Would the current status for
7 future application still apply? In other words, would
8 this be used continually to reject --
9 MR. LEGARZA: I'm going to advise you at this
10 time not to give the doctor advice about what can or
11 cannot be used for any future application that he may
12 apply for before the Nevada Board of Medical Examiners.
13 MR. QUINN: Don't be mistaken into believing
14 that or don't for one minute assume or infer that
15 anything in your licensing history or in this history
16 will not be used against you.
17 You must assume that your entire licensing
18 history in this revocation will be considered by the
19 board. You have to assume that.
20 DR. SCHMERLER: I mean, I'm trying to ask the
21 question if it's --
22 Well, I mean, I don't want to put you in a
23 position to be giving me advice. That's not my intent.
24 I'm just trying to ask is it ever going to be
25 feasible for me to realistically be in a position in the
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1 future to be relicensed?
2 MR. QUINN: I don't think anybody can answer
3 that. First of all, this entire board composition may
4 change at some time in the future when you were to or if
5 you were to reapply. So there is no way anyone could
6 give you the answer to that question.
7 And, you know, I would just like one comment.
8 I think just so that you don't misunderstand, perhaps I
9 can't speak to the mental state of mind as to each one
10 of the adjudicators, but it wasn't the commission of the
11 crime. It may not have been the fact of the commission
12 of a violation of a federal statute that is the result
13 -- resulted in a serious consequence.
14 It may be that your history and your behavior
15 in the course of -- you pled guilty, and you admitted to
16 a whole lot of dishonest conduct. And the prior
17 violation involved dishonest conduct. It may be that
18 the board is interested in protecting the public in
19 Nevada from the possibility that there is someone who is
20 a doctor who has demonstrated a lack of fear about being
21 totally dishonest for his own personal gain.
22 And that is something that the board has an
23 interest in protecting the public from with respect to
24 people who has a just desperate position with respect to
25 them as a medical doctor to a patient.
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1 PRESIDENT HUG-ENGLISH: I'm going to cut --
2 DR. SCHMERLER: One quick question.
3 PRESIDENT HUG-ENGLISH: This has to be the end
4 because we have decided and we need to move on.
5 DR. SCHMERLER: I'm sorry to extend this. Is
6 it even a possibility that someone in my position could
7 be rehabilitated?
8 PRESIDENT HUG-ENGLISH: That's really not what
9 we are here to decide today, and we can't answer the
10 questions you are asking of us.
11 We have made our decision based on this
12 mediation. That's all we can do.
13 DR. SCHMERLER: Is it even a possibility,
14 Mr. Quinn?
15 MR. QUINN: I don't know. I mean, I'm not in
16 your position and I don't know.
17 I suppose anything is possible, yes. I
18 suppose it is, yes.
19 DR. SCHMERLER: Thank you all.
20 PRESIDENT HUG-ENGLISH: Thank you.
21 Moving on. We are back to agenda item number
22 12. Do we have -- Lynnette is still here. Okay.
23 This is a discussion of a conversion from a
24 restricted license to an unrestricted license. And this
25 involves Dr. Pratt who is -- Lynnette, you are here.
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1 You can tell us about it.
2 MS. KROTKE: This is a physician who is
3 currently restricted in Elko. And the reason for that
4 is he only had one year of progressive training
5 following medical school. He is well aware of how the
6 statutes have changed recently and if he were to apply
7 today -- You want me to stop?
8 PRESIDENT HUG-ENGLISH: Go ahead.
9 MS. KROTKE: Could actually receive an
10 unrestricted license because he falls into a category of
11 the emergency medicine, family practice, preventive
12 medicine.
13 So we are in a bit of a quandary here because
14 he has completed four years out in Elko but part-time.
15 So what do we want to do with him? Do we want to have
16 him complete two more years and complete the full-time?
17 PRESIDENT HUG-ENGLISH: No. We can license
18 him based on the fact that by the new statute that he
19 has met the requirement. He is board certified in
20 emergency room medicine. And he has practiced for
21 years. I think it's a non-issue. I think we can grant
22 him an unrestricted license.
23 MS. KROTKE: We wanted to make sure because he
24 has not done it full-time he has done it part-time.
25 PRESIDENT HUG-ENGLISH: No, but even if he had
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1 not done it full-time --
2 DR. TITUS: Even if he has never practiced
3 here, he would be granted.
4 PRESIDENT HUG-ENGLISH: He would based on that
5 new statute. We have another one coming up today that
6 will be licensed because of the statute. That says if
7 they are board certified in the disciplines that they
8 meet the criteria.
9 He really meets it in my mind in two ways on
10 that. And then I certainly am willing to accept four
11 years of part-time work in a rural area. I think he
12 certainly has done his dues on that end.
13 From my perspective, I don't have a problem
14 giving him an unrestricted license.
15 MS. KROTKE: We just want to make sure that
16 the board has approval because even with these three
17 specialties, if they don't meet some of the criterion,
18 we want to make sure the board has approval.
19 DR. LUBRITZ: What criterion does he not meet?
20 MS. KROTKE: He only has one year of post
21 graduate.
22 DR. TITUS: He went to medical school here.
23 He did an internship here. And then he practiced right
24 away in the emergency room at Washoe.
25 DR. LUBRITZ: Okay.
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1 DR. TITUS: Well, he practiced for 11 years.
2 He then got board certified in emergency medicine. He
3 left and went back to Alabama and came back and is
4 working part-time in Elko.
5 So the kicker was until this new statute, they
6 can apply for full licensure after three years. But he
7 has only been there for part-time. But otherwise
8 regarding how long he practiced in Elko, doesn't matter,
9 because he does really qualify.
10 DR. LUBRITZ: Does that answer your question?
11 MS. KROTKE: We want board approval.
12 PRESIDENT HUG-ENGLISH: Do I hear a motion?
13 DR. TITUS: This is previously untread
14 territory so you should be encouraged to come to us, not
15 discouraged when you have these questions because it's
16 unclear waters here.
17 On this particular issue I move we grant him a
18 license.
19 DR. LUBRITZ: Second.
20 PRESIDENT HUG-ENGLISH: There is a motion and
21 a second to approve Dr. Pratt's application for
22 licensure. All in favor?
23 THE BOARD: Aye.
24 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
25 in favor of the motion. And the motion carries.
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1 We are putting you to work today, Lynnette.
2 The next one is discussion of questionable
3 education in Caribbean medical schools. And, Lynnette,
4 you are going to tell us about that as well.
5 MS. KROTKE: Yes. We just -- we are receiving
6 a lot of information about these schools that are listed
7 here in front of you as well as some Mexican schools.
8 We have made it a policy internally to make
9 sure that we make these applicants prove that their
10 education is equivalent to the United States or Canadian
11 schools and that they will need to do that in front of
12 the board.
13 Just on a side note here, a lot of these
14 physicians that are coming out of these schools have
15 repeated attempts at USMLE and their scores are
16 horrific. So it's something we want to make sure we
17 bring to the board to make sure that we get approval
18 from you to license these people.
19 PRESIDENT HUG-ENGLISH: There was something in
20 the material that you provided that some of the states
21 are saying that they won't accept these specific
22 schools, is that correct?
23 MS. KROTKE: Yes.
24 PRESIDENT HUG-ENGLISH: Yeah, with --
25 DR. ANWAR: What was that?
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1 MS. KROTKE: Various different boards won't
2 accept the schools.
3 DR. TITUS: These three particular ones.
4 PRESIDENT HUG-ENGLISH: So that's the question
5 we have to address as a board is whether or not we feel
6 comfortable with allowing licensure from those
7 particular schools that have some questionable criteria.
8 DR. ANWAR: I don't know if that has changed
9 or not, but World Health Organization used to accredit
10 schools around the world. And to come to the United
11 States you had to pass an entrance examination which
12 there was a conflict in the past. The people coming
13 from abroad used to think they are passing a tougher
14 examination than those here. And the examination was
15 used as a standard and any different standard, whether
16 hard or not, was considered lower. So there was a fight
17 at national level.
18 It was changed to an examination that was
19 taken by the local medical graduates as well as the
20 foreign medical graduates but it was only from those
21 accredited schools, schools that have been pre-approved.
22 So that once they have passed, which is
23 currently the US accepted examination, once they are
24 past that they are at parr with them and that is what
25 changed. Has that basis changed?
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1 PRESIDENT HUG-ENGLISH: No, I don't think so.
2 But I don't think these schools are accredited.
3 MS. KROTKE: They are in the W.H.O. Book.
4 But that doesn't mean that the State Board of Nevada
5 should accept those schools.
6 MR. LESSLY: The bottom line is you have a
7 statute that says you cannot license anyone unless they
8 graduate from a school that has the same standards as an
9 American school.
10 It doesn't really make any difference whether
11 they are in the W.H.O. book or not. Do they meet
12 standards. And you have to meet that on a case-by-case
13 basis.
14 DR. BAEPLER: Those standards are hard, and
15 I'm not familiar. And I have seen some of those medical
16 schools on some of those islands. They are not much.
17 So I asked a student a rhetorical question, How do you
18 like the island? What was it like? He had never set a
19 foot on the island. He got his two years of basic
20 science out of way by a computer. So he had a degree
21 from a medical school on an island that he never even
22 physically set foot on.
23 MS. KROTKE: Well, we have one applicant who
24 is coming for the June meeting, if he makes it, who came
25 out of a questionable medical school who has 19 attempts
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1 on various tests.
2 So these are the kind of things we are seeing,
3 and we don't feel comfortable licensing these people.
4 And we want to make sure you decide whether we want to
5 approve or have applicants coming out of these schools
6 licensed in the state of Nevada or do you want to make
7 sure they are all full boards.
8 DR. BAEPLER: One like that you just don't
9 feel comfortable just rejecting either.
10 MR. LESSLY: We don't have any authority to
11 reject.
12 DR. LUBRITZ: Is it possible -- I know you are
13 trying to stay neutral in the information that you give
14 us. But if you all have a big red flag, why don't you
15 just come right out and say it? We feel very
16 uncomfortable in A, B, C, D, E and we represented it to
17 the board for reasons A, B, C, D, E? And we would ask
18 you to look very carefully at this candidate. Because
19 sometimes you all say that, but it's in such a mild
20 manner that you can just kind of look over it.
21 MS. KROTKE: Well, I think we don't want to
22 sway you one way or the other.
23 DR. LUBRITZ: Why not?
24 MS. KROTKE: If you ask us, we will tell you.
25 But when we are presenting the information, we have to
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1 be careful, you know, not to hurt the applicant and that
2 you should make your own judgments.
3 PRESIDENT HUG-ENGLISH: Perhaps what you are
4 getting at, Joel, is that perhaps on these schools
5 listed that you have identified as problems and that
6 others have in the country and that it's out in -- the
7 press certainly has an issue as well, that we make sure
8 that they are full boarded for now.
9 It looks to me Iowa is addressing this at a
10 federation level and is going to be asking for guidance
11 for stated individuals for what we can do.
12 But, in the meantime, until we have some more
13 guidance, perhaps that's sort of an intermediate step
14 that we can have them all come and be evaluated by this
15 board.
16 MS. KROTKE: That's what I'm presenting.
17 That's what we have elected to do to let you know and
18 inform you.
19 MR. CLARK: And if you see a red flag stuck on
20 an application, pay attention.
21 DR. BAEPLER: I think at one point in keeping
22 with what Dr. Lubritz said, you guys are experts in
23 looking at these applications. And you can spot a
24 troublesome area that those of us who don't look at
25 these forms would never see.
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1 MS. KROTKE: Definitely.
2 DR. BAEPLER: Those you probably should bring
3 to our attention.
4 MS. KROTKE: We will make sure they are
5 flagged or bolded or --
6 DR. ANWAR: Because what we can do at this
7 point is on a case-by-case level where a candidate
8 appears to be a weak candidate and not up to snuff as
9 per our standards for licensure are considered, and we
10 can vote on a case-by-case basis. But make a generic
11 policy to exclude schools may exclude candidates who are
12 good candidates who want to come here.
13 PRESIDENT HUG-ENGLISH: So do we need a motion
14 to do that or are you guys doing it anyway?
15 MS. KROTKE: We are doing it anyway.
16 PRESIDENT HUG-ENGLISH: Okay. So we will
17 continue to have you do that and maybe after the meeting
18 in April when we come back, you know, have a different
19 feeling about what we need to do.
20 I think hopefully that it will be addressed in
21 that meeting.
22 I appreciate you bringing it to our attention
23 because I think, again, we don't have a sense as to what
24 schools might be problematic that you are not getting
25 the information you need.
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1 MR. CLARK: They can put in bold-face type,
2 problem areas that they see for your review when you get
3 one of the applicant files.
4 PRESIDENT HUG-ENGLISH: That will be helpful.
5 That will be very helpful. I think that would be great
6 to include.
7 DR. LUBRITZ: It will be nice too not just
8 with the school.
9 DR. ANWAR: Everything.
10 DR. LUBRITZ: You have to remember, when we
11 get all these to look at, you are very familiar. You
12 have been through the things. And as thorough as we try
13 to be, it would be -- just anecdotally for me it would
14 be a big help if you have a concern, you let me know
15 about that concern. And I will look particularly at
16 that. It doesn't mean that you have decided for me, but
17 it let's me know you have had some problem and we're
18 just given a heads up.
19 MS. KROTKE: So you want a note from the
20 license specialist this is the --
21 DR. BAEPLER: In many instances the appearance
22 because they answered affirmatively to this question or
23 whatever so that type of thing. If there is anything
24 other than that, questionable school or something like
25 that, let us know about that.
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1 MS. KROTKE: Okay. We are trying to divide
2 all the information so that you can find --
3 PRESIDENT HUG-ENGLISH: And I want to just say
4 to you how helpful that is. It makes such a difference
5 in going through the individuals because it's so much
6 easier to identify. So thank you for that.
7 We'll move on to the website with Laurie.
8 Give us an update.
9 MS. MUNSON: The website has been an ongoing
10 work in progress for quite some time.
11 DR. ANWAR: Can you see the website?
12 MS. MUNSON: I will work on that for next
13 time. I don't know if anyone -- have you looked at it
14 recently? Both former staff as well as current staff
15 have been working very hard to not only bring the
16 website into complete compliance with all statutory
17 requirements but also to try and make it easier to
18 navigate, a little more user friendly for the public,
19 provide as much information to the public and/or
20 licensees as we can.
21 Some recent additions for some of you who
22 haven't seen them we have added a frequently asked
23 question section, a forms section, which includes
24 application forms, complaint forms, and the like, a
25 section that contains some of the board's financial
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1 statements, whatever the most current balance sheet in
2 the profit and loss versus actual budget sheet, as well
3 as the most recent in June 2003.
4 Also, we have added the page where someone can
5 go in and look up all of the disciplinary actions by
6 physician or licensee alphabetically. That information
7 not only includes the names and the description of
8 disciplinary action or actions, but also gives the
9 county, city, state of a licensee and the scope of
10 practice.
11 And as far as the educational information, we
12 are still working with that. The board gave us
13 authority and we have hired a full-time temporary
14 data-entry person in late December who has been working
15 to review all the board's licensee files and compare the
16 educational information in those files with what we have
17 on the database and make any corrections as necessary.
18 That is approximately 30 percent complete.
19 And we anticipate having it fully completed in
20 approximately four months at which time we will be
21 prepared to add that information to the website and the
22 public will be able to review that as well.
23 DR. BAEPLER: I like the updates that you have
24 made. I have checked it out several times, and most
25 recently this last week, and you can tell it is
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1 beginning to get a lot better.
2 MS. MUNSON: We are working on it. I have
3 actually spoken with Gary Ogelsby who is the chief
4 information officer for the Arizona board since that
5 seems to be the website that people like. And I have
6 looked at it. I have been working with him.
7 He has actually offered to consult with me,
8 possibly give me some suggestions, if the board is
9 interested in that and, you know, upgrading it.
10 We definitely want to keep working with it to
11 make it as easy to access as possible. And any
12 suggestions that you have, things we can add to it, we
13 can pretty much do just about anything. We are getting
14 to that point. So anything the board would like to put
15 on there, we can certainly endeavor to do.
16 DR. ANWAR: Can physicians provide information
17 that they would like to see on that site as information
18 regarding the physicians?
19 DR. BAEPLER: Like best laser surgery in town?
20 DR. ANWAR: No. Like the information is
21 incomplete and somebody has two boards or three boards
22 or something special about that doctor?
23 MS. MUNSON: We have received some phone calls
24 from licensees who have said there is this or that on
25 there that, this has changed or that has changed, please
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1 update it. So I think the website is actually a good
2 tool --
3 DR. ANWAR: But they can't do it themselves?
4 MS. MUNSON: No. I have the power.
5 PRESIDENT HUG-ENGLISH: You are the web
6 master.
7 I think too that -- I have to thank Laurie.
8 She has taken this really leaps and bounds in a really
9 short period of time. And this is recognized. We have
10 over the year and a half really gotten the software and
11 gotten under way and really working on getting the
12 website updated. And I think it is a work in progress.
13 There will be continual updating and changes that will
14 need to be made. But I think that the changes that have
15 occurred have been very positive. And I think that the
16 website in large part due to you, Laurie, has come a
17 long way.
18 So thank you.
19 MS. MUNSON: Thank you.
20 I do want to mention one other thing briefly.
21 At the last meeting someone asked about putting a
22 counter on the side. We have done that. It is a
23 private counter at this point so the public doesn't see
24 it. We just didn't see a benefit in that. You know, it
25 gets in the way. We can make the public aware if the
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1 board so desired.
2 PRESIDENT HUG-ENGLISH: I think it's needed.
3 DR. BAEPLER: There is a number of hits.
4 MS. MUNSON: That was one that was on there
5 before. I'm not sure where that came from. Before I
6 was working on it. On one particular page.
7 We have placed a new one on every page, and I
8 was thinking of deleting that particular one and
9 starting new. But that's something I wanted to ask you.
10 I don't know how long that has been counting. I don't
11 know how accurate it is. I don't know where it came
12 from.
13 This particular one we actually purchased
14 because our program would not do what we needed it to
15 do. And it only went on line last Sunday. I want to
16 tell you we already had 1800 unique hits in five days,
17 2554 total hits which would be return visitors as well
18 as if they review more than one-page. I think it's
19 definitely doing a good job of being used. And I think
20 we can really use that tool to get information out.
21 MR. QUINN: What is that number in five days,
22 1,803 unique visitors?
23 DR. TITUS: Was that a significant increase
24 from the north after the newspaper article recently?
25 MS. MUNSON: Unfortunately, I couldn't tell
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1 you that because I just put it on Sunday.
2 PRESIDENT HUG-ENGLISH: We really don't have a
3 sense of how many hits we were getting before then.
4 MS. MUNSON: I'm sorry about that.
5 PRESIDENT HUG-ENGLISH: Well, thank you for
6 your work on that.
7 And, again, I will invite all the board
8 members to check out the website because I think it is
9 educational for us to see what is on there.
10 MS. KROTKE: Check your information.
11 PRESIDENT HUG-ENGLISH: That's right. Okay.
12 Agenda item 16 is your executive staff
13 reports. And, Larry, do you want to start that off?
14 MR. LESSLY: I will let Tony do this one.
15 PRESIDENT HUG-ENGLISH: Okay.
16 MR. CLARK: I don't have anything specific
17 other than I sent out a memorandum asking all board
18 members to submit any thoughts or desires they had for
19 potential legislation so that we could discuss those
20 items at the June meeting.
21 We have gotten several in. If any of you have
22 any additional ideas, please send them to us as quickly
23 as possible so we can get them on the list and discuss
24 them at the June meeting.
25 Other than that, staff is working hard and
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1 we're trying to keep on top of things.
2 PRESIDENT HUG-ENGLISH: Great. There also
3 under this is consideration for request for staff
4 attendance at meetings.
5 MR. CLARK: Ah, yeah. The Washoe County
6 Medical Society has a spring meeting internship program
7 that we would like to send two of the investigators,
8 Trent Hiett and Jennifer Sloan. There is no cost. It
9 has to do with time off.
10 Debbie Swartz, and this is not on here, would
11 like to attend a state personnel training session in
12 May. It's a one-day training session. And since the
13 employees here are state personnel, it would be helpful
14 to have somebody updated on that.
15 And the Federation of State Medical Boards has
16 a new executive orientation on June 28 and 29th. And
17 Laurie Munson and I would like to attend that.
18 DR. BAEPLER: Just a question. I think that
19 Washoe County program would be very, very interesting.
20 I'm just trying to make the connection between
21 the investigator and the nature of the program.
22 Actually go in and observe surgery and do all kinds of
23 really neat things. I just wondered how it hooks up
24 with investigative functions.
25 MR. COOPER: The way to accept it is you just
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1 don't go in and watch surgery. You get to spend half a
2 day in the office.
3 You meet the office manager. You see how
4 records are compiled, how records move, what records
5 exist.
6 Since the investigator is the one who has to
7 go out and get these records, it's nice to know what
8 exists in an office, what a practice has to give us.
9 What should be in the chart. That helps also.
10 Plus, it helps them meet the doctors. It's
11 good PR for the medical board itself and for the
12 investigative part especially.
13 Hopefully our department won't see these
14 doctors' names come across.
15 DR. BAEPLER: Take good notes as to what you
16 see.
17 MR. COOPER: Right. And then there is an
18 ingress and egress dinner where they get to meet other
19 people who are in the health care community locally.
20 And for an investigator to make contacts, that's your
21 bread and butter to know who is out there and who is in
22 charge of things.
23 You get to meet hospital staff, the people who
24 run the medical records in hospitals. Those kind of
25 contacts are worth attending.
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1 DR. BAEPLER: It really looked like a nice
2 program.
3 MS. KROTKE: I think it helps the
4 investigators with medical terminology, you know.
5 PRESIDENT HUG-ENGLISH: Okay. Do you need a
6 motion to approve those?
7 DR. BAEPLER: I move we approve the program.
8 DR. TITUS: Second.
9 PRESIDENT HUG-ENGLISH: All in favor?
10 THE BOARD: Aye.
11 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
12 in favor as well. Those all sound like good meetings.
13 How about the update on the video-conferencing
14 equipment?
15 MS. MUNSON: It's a very brief update. We
16 have added extra microphones, five of them, as you can
17 see to make it easier hopefully for the people in Las
18 Vegas to hear the proceedings here in Reno.
19 All of the video-conferencing equipment is
20 fully operational and including especially the VCR
21 camera. I have tested it. We can play videos.
22 PRESIDENT HUG-ENGLISH: Now that you tested
23 it, we probably never will need it.
24 MS. MUNSON: Exactly. Now that it's working
25 today we probably will never need it.
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1 All the investigators of staff and myself
2 attended a formal training session with the Pollycom
3 people, the ones bringing you this equipment, and other
4 staff members may attend in the future.
5 And we will make sure we keep you advised on
6 any changes and updates and newfangled things that come
7 our way to use them.
8 PRESIDENT HUG-ENGLISH: Okay. Great.
9 The report on practitioners of respiratory
10 care, status of renewal registration. Is that you,
11 Lynnette?
12 MS. KROTKE: Yes. I will just sit back here.
13 We did two mass mailings. The first one was October
14 2003. We got no response out of that mailing.
15 We did a second mailing January 2004. Out of
16 that we have 790 reviewing respiratory therapists. We
17 have ten that requested non-renewal and we suspended 144
18 for nonpayment. And five of those 144 have reinstated
19 to this date.
20 DR. BAEPLER: The deadline has passed?
21 MS. KROTKE: Yes.
22 DR. BAEPLER: Where did we miss our budget
23 projections? We had projected a revenue of $70,000 and
24 we collected $52,000. Were we overly optimistic on the
25 percentage of renewals?
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1 MS. KROTKE: I think a lot of these
2 respiratory people are travelers, and we can't find
3 them. So during the first mailing we made numerous
4 attempts finding people on the envelopes that came back
5 were bad addresses. And we would research their
6 licensing file to get any information of finding them,
7 but basically we are stuck.
8 DR. BAEPLER: What is to prevent those
9 travelers from coming through town and practicing and
10 travel out without a license?
11 MS. KROTKE: Well, the one thing we noticed
12 this time -- not this time. We noticed that the
13 hospitals are being very observant about who is
14 compliant and who has renewed.
15 DR. BAEPLER: We need that.
16 MS. KROTKE: So it's been a good thing.
17 PRESIDENT HUG-ENGLISH: Okay. How about
18 consideration of physicians use of credentialing
19 entities? Is that you, too?
20 MS. KROTKE: Yes. We are having some more
21 issues not as bad as U.S. Medical Licensing, but we are
22 having more issues. And we are just letting you know
23 that, you know, if it becomes -- if certain entities
24 become a problem, that we would like to pull the plug
25 off the middle man.
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1 So we did have an issue come up actually
2 recently. It was pretty scary. U.S. Medical Licensing,
3 who we no longer accept, I found a notarization in an
4 FCVS packet which is the Federation of State Medical
5 Board Credentialing Service. Steve made a call to them
6 and alerted them that this was going on. And there is
7 -- a lot of these credentialing services make us
8 nervous. And we want to make sure we are licensing the
9 person that is notarized on that application.
10 So we are just updating you, communicating,
11 and letting you know that there are a few, two in Utah
12 right now, that are really causing us some havoc.
13 I don't know your feelings on that, you know.
14 Are we allowed to take out the credentialing service all
15 together? Do we not want to do that?
16 PRESIDENT HUG-ENGLISH: I think the board made
17 its decision on one particular one last time that it was
18 bad enough. So I think if you are finding others that
19 rise to that level, I would bring them forward to the
20 board and let the board make the determination whether
21 they feel they not want to use or accept those anymore.
22 But I appreciate the update. Thank you. That
23 is concerning. I notice there are a couple in here for
24 this meeting that that was an issue.
25 Dr. Lubritz, did you have something?
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1 DR. LUBRITZ: Is it up to the point now that
2 you feel that perhaps the only credentialing services
3 that you would accept would be those that you know here
4 in the state?
5 MS. KROTKE: I think credentialing services
6 actually lengthen the process for the physicians.
7 DR. LUBRITZ: But that's not our problem.
8 It's a liability on your part.
9 MS. KROTKE: Yes. I think it's easier to work
10 directly with the physicians.
11 DR. TITUS: I would discourage people using a
12 credentialing service. I think we can make a standard
13 that we don't accept that.
14 DR. JONES: The nice thing about it is you can
15 read them.
16 DR. TITUS: You can have an office manager
17 type up your form. You can have somebody assist you in
18 doing that, but then you better be the one sending it
19 in.
20 DR. BAEPLER: You better sign it too.
21 PRESIDENT HUG-ENGLISH: I guess maybe I would
22 like to hear from you, Lynnette, but that may be too
23 broad. Are there some that are doing a fairly decent
24 job?
25 MS. KROTKE: There are some. But the
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1 physicians who are really -- have been out there for a
2 long time they have a lot of verification to get.
3 Sometimes, maybe ten percent of the time, they are
4 helpful.
5 I would say 90 percent of time they just
6 complicate the entire process.
7 So you have got these entities scanning forms,
8 removing information, erasing our date stamps. It's a
9 mess.
10 If I had my way, I would pull the plug on
11 credentialing services.
12 It's kind of a new way to make money.
13 Physicians are very busy. They have found a market. So
14 you know we have a lot of problems with these people.
15 DR. ANWAR: There definitely is a market for
16 it. That's for sure.
17 DR. LUBRITZ: Would you entertain a motion?
18 PRESIDENT HUG-ENGLISH: Sure. I just want to
19 make sure we are not jumping the gun here a little bit
20 because I do think the way the practice of medicine is
21 and a lot of these physicians who have multiple,
22 multiple contracts with lots of different entities I
23 think use some of these services.
24 And I think some of them use them responsibly,
25 have them help with the preliminary part of the
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1 application and then take over and make sure everything
2 is correct. And I think for those instances I think it
3 probably serves a purpose for some physicians.
4 And there are others who, you know, don't even
5 sign the thing. And I think that obviously is a real
6 concern to us and we addressed that last time.
7 DR. BAEPLER: Do you know if the medical
8 school encourages the residents to use that?
9 PRESIDENT HUG-ENGLISH: No, there is no
10 encouragement.
11 DR. LUBRITZ: Being very pragmatic about that
12 that physician who you were talking about who were
13 working for multiple people and have multiple state
14 licenses, I figure that's their problem. They chose to
15 do that. It shouldn't be our problem.
16 We should make it as easy as we can and
17 reliable as we can for our -- for us, licensing,
18 credentialing, than kind of thing.
19 And if the doctor doesn't have the time to
20 fill it out himself, you know, or have someone helping
21 him fill it out and send it in himself, that's his
22 choice.
23 PRESIDENT HUG-ENGLISH: Do we know what other
24 boards -- are there any boards that don't accept
25 credentialing agencies? We know that information?
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1 MS. KROTKE: What's basically -- they send --
2 the physician sends their CV, the entity calls us for an
3 application. We try -- you know, now they are on the
4 internet so we have lost a lot of our power to know
5 where we are sending the information.
6 But we know just by the people we have been
7 dealing with where these credentialing entities are.
8 And we are trying to bypass them and send it to the
9 physician and get the correct information.
10 So the application corrections and so forth
11 are going to the entity and then the doctor, maybe, to
12 get corrected. So it's this --
13 PRESIDENT HUG-ENGLISH: Triangle.
14 MS. KROTKE: Triangle of mess. So I don't
15 know.
16 DR. ANWAR: My opinion on that would be that
17 since we credential applications no matter which route
18 it takes, whether it takes a longer route or shorter
19 route, that we review it on a case-by-case basis.
20 If we do find a problem like we did with the
21 US then we pull the plug rather than doing a blanket
22 sort of thing that we are not going to accept any
23 entities of any sort.
24 PRESIDENT HUG-ENGLISH: Okay.
25 DR. LUBRITZ: I withdraw my motion.
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1 PRESIDENT HUG-ENGLISH: All right. So, I
2 guess, Lynnette, we will just wait until we hear from
3 you.
4 But I do think that certainly we are all
5 concerned about it. So if there are others that become
6 as big an issue as the one we had last time, definitely
7 bring them forward because I think we don't want to be
8 dealing with that.
9 Any informational items under 16? No.
10 Okay. Legal reports.
11 MR. LEGARZA: I don't have any.
12 PRESIDENT HUG-ENGLISH: None?
13 MR. LEGARZA: No.
14 PRESIDENT HUG-ENGLISH: How about Steve?
15 MR. LEGARZA: Steve wants about half an hour
16 of your time.
17 PRESIDENT HUG-ENGLISH: You're up.
18 MR. QUINN: There are four court cases
19 pending. The first one is Dr. Mishler, February 20th,
20 the 9th Second Circuit affirmed the district court's
21 summary judgment against Dr. Mishler in favor of the
22 individual board members named. Stating, After 17 years
23 of litigation this case needs to come to an end.
24 Dr. Mishler has until March 20th to file a
25 request for rehearing. The time for that may be over.
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1 But I think this case may be dying. I think it may be
2 dead.
3 The second case is Dr. Robert Rutledge who you
4 may recall is the person whose application was rejected
5 on the basis that he answered incorrectly in a prior
6 application.
7 He petitioned for a judicial review and on
8 March 8th the Washoe District Court reversed the board's
9 denial on Dr. Rutledge's 2003 application.
10 The decision was made on the grounds that the
11 board improperly considered his 2002 application.
12 For those who understand the meaning of the
13 word, the court utilized the estoppel doctrine, saying
14 that the board was estopped to look backwards.
15 That's why I made that statement that I make
16 to Dr. Schmerler saying there is no way that you should
17 ever understand that the board will ever be looking at
18 what he has done in the past.
19 And the judge also thought that there was a
20 factual basis to conclude that the answer that he gave
21 to the question -- whether that negative answer he gave
22 to the question when he was under investigation was a
23 correct answer. Although, I seriously disagree with the
24 Court's statement that there was evidence in the record
25 to that affect.
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1 I have a notice of appeal prepared to take
2 that to ask for review by the Nevada Supreme Court. I
3 anticipate that -- in fact, I got a letter today that I
4 didn't have a chance to read. It was faxed to me, and I
5 haven't read it. But the substance of it, I believe, is
6 that Dr. Rutledge wants to come back with some sort of a
7 conciliatory approach to this board and see if there is
8 any way to reconcile the differences and try to obtain a
9 license from the board.
10 And, specifically, he would like to have the
11 matter of his application put on the June agenda. So I
12 don't know. I could discuss that with you if you all
13 have any questions or leave it alone.
14 The third case is Dr. Mower.
15 DR. MONTOYA: Before you go on, if we bring
16 that back to discuss the Dr. Rutledge case, we cannot
17 consider the earlier application? Are we going to be
18 bound by that district judge's --
19 MR. QUINN: That's a legal decision at this
20 point. I can take that legal decision to the supreme
21 court.
22 DR. MONTOYA: I'm talking about in time for
23 the June meeting?
24 MR. QUINN: No. Nothing will be done by the
25 time of the June meeting.
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1 So we will be on appeal. He will have won
2 that round. And the supreme court will have the final
3 say. And some time between now and then Dr. Rutledge is
4 qualified. He offended our board with his candor,
5 basically, and/or it appears he is qualified.
6 MR. CLARK: Or lack there of.
7 DR. BAEPLER: We have a parallel case today
8 almost exactly parallel with that.
9 DR. LUBRITZ: Does this mean we can no longer
10 look backwards? If we can't, he can forget about it.
11 Because the guy can put in an application and the very
12 next time change it. And if we are precluded from doing
13 that --
14 MR. QUINN: No, it doesn't. I mean, I think
15 that Judge Elliott was the district judge who decided
16 this case here in Washoe County was favorably persuaded
17 perhaps by well-known lawyers representing Dr. Rutledge
18 in the community. That's one thing I can say may have
19 swayed him in his belief.
20 As far as avoiding that in the future, Judge
21 Elliott could not have arrived at that legal conclusion
22 had there been any indication in the formal proceeding
23 or notification to him that when he withdraws, that
24 withdrawal is with prejudice to him from the standpoint
25 that his application will forever be subject to be
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1 reviewed. And that was not done. Not that I think that
2 was a fault on our part.
3 Then Judge Elliott what he did was he inferred
4 that there is a representation, essentially, to
5 Dr. Rutledge that we will not look to that because we
6 allowed him to withdraw it almost as if it were void.
7 DR. BAEPLER: Pretend it didn't happen.
8 MR. QUINN: Yes, that's right. I think that's
9 a legal fiction, but I also think that the nature of the
10 Nevada Supreme Court is such that the outcome is fairly
11 unpredictable.
12 DR. MONTOYA: Question.
13 MR. QUINN: I cannot say that I think that we
14 will -- will or will not prevail on the issue of whether
15 he answered the question correctly. I don't think there
16 are any facts that suggest he did.
17 DR. ANWAR: Question. From legal standard
18 exactly same issue that has me concerned. And I have
19 been thinking -- obviously I don't have an answer. But
20 it's a legal issue if somebody has misrepresented or
21 lied on an application and comes back later on when it
22 was withdrawn or not accepted or whatever happened to
23 that but later on is allowed to apply again. He comes
24 back six months, a year later, and replies. And he says
25 that I'm sorry. I misinformed the board on my previous
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1 application. I apologize, but I would like to be
2 reconsidered. What are our grounds as a legal point of
3 view to really reconsider?
4 MR. QUINN: That's the case we have this
5 afternoon.
6 I think you have the right to reconsider just
7 as you have the right to accept an application from
8 Dr. Schmerler who has been revoked.
9 And I think you can reconsider on the basis of
10 your judgment of whether that person is qualified and
11 whether that person's application should be accepted or
12 rejected on the basis of some grounds for denial one of
13 which is seeking to obtain a license by an incorrect or
14 a false statement.
15 DR. ANWAR: My question is everything else is
16 okay. The only problem with the application is
17 incorrect statement on his previous application and now
18 he apologizes or she apologizes for that and corrects
19 that. What does our legal -- how do we handle that from
20 a legal end?
21 MR. QUINN: That's exactly what Rutledge did
22 because he came back in and said, Oh, I answered it
23 incorrectly. And I pointed out to the judge -- because
24 we have a transcript of the second time. I pointed out
25 to the judge about five instances in his interview where
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1 he admitted that his answer was incorrect.
2 PRESIDENT HUG-ENGLISH: But he never really
3 apologized.
4 MR. QUINN: No, he didn't.
5 PRESIDENT HUG-ENGLISH: Until we pinned him
6 down and finally he got there. But it took a very long
7 time. And I think that was one of the issues that this
8 board had with that case is that he really didn't ever
9 feel like he was very conciliatory about it.
10 And, I think, that's the situation that you
11 are asking is that if someone comes, made a mistake, we
12 allow them to withdraw and they come back and say, you
13 know, I really made a dumb mistake. I'm really sorry
14 about it. I think that's the difference.
15 DR. BAEPLER: It's demeanor.
16 MR. QUINN: That's a technical answer. First
17 of all, hereafter just to prevent this such of thing
18 from occurring, should we in our -- should the board in
19 its generosity and as a matter of courtesy allow someone
20 to withdraw which I take we care to do from time to
21 time.
22 When you do it, make sure that there is some
23 follow-up letter that documents that the withdrawal is
24 without prejudice to refer to that document in the
25 future. And to use whatever was wrong or defective to
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1 be considered in the future.
2 Now that gives you the opportunity to continue
3 to exercise the withdrawal, to grant that courtesy.
4 DR. BAEPLER: But you don't pretend it didn't
5 happen. You note that it did.
6 MR. QUINN: You note that it did happen, and
7 you note the right to bring it up again.
8 I don't think that the judge was accurate, but
9 he is the judge, see. And this prevents him from doing
10 that.
11 DR. LUBRITZ: Let's take it a step forward.
12 Do you not feel, given what you have just said, that on
13 every application, not talking about those that we allow
14 to withdraw, on every application that we reject, it
15 should be with prejudice so that we can go back if they
16 reapply. Don't get a judge to tell us we can't look
17 back.
18 MR. QUINN: I think that's reasonable. I
19 think in the case of a denial, it is, in fact,
20 documented because you write them and tell them I'm
21 denying on the basis of this application which has a
22 defect.
23 DR. LUBRITZ: Should you reapply --
24 MR. QUINN: We will look to your conduct. I
25 think that's an advisable step to include in the letter.
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1 DR. BAEPLER: Would we have the authority to
2 quote with prejudice -- the judge can dismiss a case
3 with prejudice or something like that. But a board like
4 this, can we use that phraseology in the same context?
5 MR. QUINN: What we don't want to do is use
6 the phrase and have it misconstrued. So say it in plain
7 English, We will reserve the right to look at this
8 application and what took place here should you choose
9 to come back and address us in the future.
10 DR. LUBRITZ: Let me ask something else. What
11 would happen if the board ignores what the judge said
12 that you can't look back? What if we say, Judge, you
13 are wrong. You know, this is our board. We make the
14 rules. You don't make the rules.
15 DR. ANWAR: You can't do that.
16 MR. QUINN: It seems to me that Dr. Rutledge
17 or a person in that position could ask a court to order
18 the board to do something which it is legally required
19 to do. That is a legitimate claim that judges can
20 grant.
21 And the basis would be that the board is
22 legally required to grant the license because a court
23 has overturned and -- you know, a court on appeal has
24 reviewed its denial and determined -- and this is the
25 determination: The denial was unlawful and erroneous.
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1 And the Court then ordered the board to reconsider the
2 application in light of this -- of its determination.
3 Should we fail to do that, I think Dr Rutledge
4 would have a legitimate action to seek a court order to
5 mandate the board to do something he was supposed to do.
6 MR. LEGARZA: The short answer to the question
7 is the Court orders you to do something, you do it or
8 you appeal it. And you may have to do if you don't get
9 a stay.
10 DR. LUBRITZ: We are appealing?
11 DR. TITUS: Joel, we have been accused of
12 being arrogant already. I think that would be over the
13 top.
14 MR. LEGARZA: This historically has been
15 something we have talked about for a long time and said
16 don't let them withdraw, deny it. And now this judge
17 has basically said -- what he has done is he has jumped
18 up and said you people have let this guy withdraw his
19 application. He was never married. It's an annulment.
20 And that's what Steve now has to fight.
21 So you have to be real careful of what Steve
22 is saying. If you are going to let these people
23 withdraw the applications -- Larry and I have always
24 taken the position that you shouldn't, but you do. You
25 have to make it perfectly clear that you are allowing
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1 them to withdraw the application. And Steve will have
2 the right language to tell them, but anything you have
3 said in the past can and will be used against you in the
4 future.
5 I think the judge is result oriented in his
6 finding. It's grounds for appeal.
7 It used to be one member of this board would
8 do this stuff informally out in the hallway and come
9 back in and say so and so is withdrawing his
10 application. And, no, you can't do that. So you just
11 have to be careful.
12 PRESIDENT HUG-ENGLISH: So, Steve, just so
13 that I understand for June because you are appealing it
14 now will he come to our June meeting or does he have to
15 wait until the appeal goes through?
16 MR. QUINN: He doesn't have to wait. What he
17 is trying to do in the interim is see if he can resolve
18 this with -- settle the court case. But obviously the
19 only grounds that are settled -- that are acceptable to
20 him are licensure.
21 DR. LUBRITZ: Do we have to let him come back?
22 MR. QUINN: No, we don't.
23 DR. LUBRITZ: Then why would we? Why would
24 we?
25 MR. LEGARZA: It may be to the benefit of the
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1 board in the long run to settle this thing. It may be.
2 MR. QUINN: It may be. He could also initiate
3 some other litigation and cause a bunch of expense.
4 The Mishler case --
5 DR. LUBRITZ: That's what you are here for.
6 MR. QUINN: The Mishler case is one of those
7 cases where a doctor sued because he didn't like what
8 happened.
9 Dr. Rutledge could do that. And so I think he
10 could.
11 DR. LUBRITZ: He is not practicing here. He
12 can't practice here, right, until he gets a license.
13 Figure that's your work.
14 MR. QUINN: Third one is Mower. And Mower is
15 on appeal to the supreme court. There is no present
16 scheduled activity. The scheduled activity is the
17 filing of briefs.
18 Once the briefs are filed, the next thing is
19 we wait until the supreme court sets it for argument.
20 There is no scheduled brief filing. It was referred to
21 the mediation, but the mediator called me up and said,
22 you know, do you see any problem here? And I said,
23 Well, no, I don't. So I think he is going to take it
24 up.
25 PRESIDENT HUG-ENGLISH: Did the district court
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1 uphold our --
2 MR. QUINN: Yes, the district court upheld.
3 There are a couple of -- just on a side note, there are
4 a couple of significant legal issues that are --
5 DR. BAEPLER: Like murder.
6 MR. QUINN: No. Legal technicalities. The
7 standards of proof in -- pursuant to the statute for our
8 adjudication is -- the standard is a preponderance of
9 evidence.
10 There is a split in the country, I think,
11 among those states that have considered the issue
12 whether a preponderance of evidence does or does not
13 violate a licensee's constitutional due process to his
14 licensure because the licensure is such an important
15 thing that the standard of proof should be that
16 intermediate standard which is clear and convincing
17 evidence, one step below reasonable doubt which is
18 criminal evidence, and there is -- to my knowledge,
19 there is no Nevada Supreme Court decision on this.
20 But I will tell you if his lawyer does a good
21 job briefing it, my view is our Nevada Supreme Court is
22 more likely than not to require the higher standard of
23 proof.
24 MS. BIBLE: You could argue by the evidence
25 that was presented that the higher burden was used by
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1 the courts.
2 MR. QUINN: I don't know I would argue that.
3 But I think what the supreme court would be more likely
4 to do is remand it, and we would have to represent it
5 for adjudication under those standards.
6 DR. BAEPLER: Doesn't the statute define what
7 level --
8 MR. QUINN: You know, the judges are not bound
9 by the --
10 DR. LUBRITZ: Can I make a suggestion that we
11 move on.
12 MR. QUINN: There is one more case.
13 Dr. De Tar has filed an action against the
14 board. And I think my boss over there Mr. Lessly
15 mandate the board to investigate St. Mary's -- a
16 hospital's credentialing committee that conducted a
17 judicial review of action upon him on the basis of
18 claimed false statements regarding quality of care.
19 And we have taken the position that the board
20 lacks jurisdiction over that type of complaint. And so
21 he has filed a lawsuit, and I filed a motion to dismiss
22 and his response is due. And he hasn't filed it yet.
23 MR. CLARK: Is he representing himself?
24 MR. QUINN: No, he has now got a -- retained
25 an attorney.
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1 PRESIDENT HUG-ENGLISH: Thank you.
2 MR. QUINN: Oh, okay. I was going to talk
3 about general adjudications under legal reports. I see
4 as my duty as deputy general counsel to prosecute
5 patient-care complaints where pure reviewers found
6 malpractice committed. And will prosecute this action
7 on other statutory grounds where the action exists.
8 I currently have about 10 cases already
9 approved for formal action and am preparing another six
10 cases for consideration for formal actions by
11 investigative committees by June -- before the June
12 meeting.
13 There have been legislative changes which we
14 are all familiar with that have made pursuing formal
15 action more difficult because unless a felony is related
16 to the practice or the ability to practice medicine, it
17 is not grounds for disciplinary action.
18 And moral turpitude and unprofessional conduct
19 are no longer grounds for disciplinary action unless
20 such things as drug possession, distribution and spouse
21 abuse, family abuse, sexual assault, and conviction of
22 violent crimes, murder, assault, battery so forth are no
23 longer grounds for discipline, unless they are related
24 to the practice or ability to practice.
25 MS. BIBLE: Don't you think you can argue a
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1 lot of those things are related to the practice of
2 medicine? I'm aware of that language. My position I
3 would still argue that anything that is, you know,
4 integrity or, you know, affects a person's character,
5 their trustworthiness, I think you can argue it affects
6 the practice of the profession.
7 MR. QUINN: It's a stretch.
8 MS. BIBLE: If you are a landscape architect,
9 it's not the same as if you are a physician,
10 chiropractor, a nurse, or any of those that deal with
11 patient's vulnerability and patient trust and that sort
12 of thing.
13 DR. BAEPLER: I would like to think I was
14 right.
15 DR. LUBRITZ: That was exactly the supreme
16 court case you said that you quoted for the doctor
17 sitting over here.
18 MR. QUINN: That's in a jurisdiction that was
19 like ours where moral turpitude was grounds. But the
20 statute -- but the legislature in 2003 took that out as
21 grounds --
22 MS. BIBLE: They took it out, but I don't
23 think there is any history on the reasons for that.
24 Because I listened to all the hearings and there were a
25 lot of them related to your bill. And I don't remember
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1 any discussions that was -- just it seemed like it just
2 appeared in there. But I could be wrong.
3 So I think you could still make that argument
4 that a lot of those other crimes -- because there are
5 not that many crimes that are related to your
6 practice --
7 MR. QUINN: Any of those other crimes if
8 committed in the course of the practicing in the office
9 during practicing hours against the patient related to a
10 patient or something, of course, would be related.
11 Unless by contrast. I think you can make the
12 argument, you can make it. But, honestly, I would
13 disagree that it would be made carefully and in good
14 faith.
15 PRESIDENT HUG-ENGLISH: I would certainly hope
16 that that long list that you read to us that we are not
17 making a decision as a board or investigative committee
18 not to file on cases such as those you just read because
19 of this new legislation.
20 DR. BAEPLER: No, we decided to go after --
21 PRESIDENT HUG-ENGLISH: I think we should
22 because they are very serious charges that you have read
23 in that list and for us to ignore that based on the last
24 legislative changing would be negligent on the part of
25 this board.
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1 And if we go forward with the complainant and
2 it gets legally challenged and they tell us we can't do
3 it, that's fine. But I think to ignore those at this
4 level and not file on those based on that new statute --
5 DR. BAEPLER: There are legislators that have
6 gone public on the fact that these things still can be
7 used by the board.
8 And the only way to test -- and if not, they
9 will change the legislation. But the only way to prove
10 that is to test it in the courts.
11 MR. LEGARZA: That's going to be a staff
12 recommendation for legislation next time to go back to
13 where it was.
14 This whole thing started with one legislator
15 who wanted to do away with having a felony conviction
16 for being grounds for denial of licensure. That's where
17 it started. And they lost it in the shuffle down there.
18 I mean, see, our law says it's grounds for
19 disciplinary action or denial of licensure under the
20 same thing.
21 So I have already worked up some stuff that
22 talks about, except in the certain situations where --
23 of denial of licensure. Maybe you don't want a felony
24 conviction to be denial of licensure.
25 But to go back to where you were. I agree
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1 with Steve. I understand Charolette's arguments, but I
2 agree with Steve.
3 DR. BAEPLER: To answer your concerns --
4 PRESIDENT HUG-ENGLISH: I think the issue is
5 we have two years before we get this changed and for us
6 to ignore those kinds of very serious charges or not do
7 anything or investigate them, I think we are being
8 negligent as a board. And even if we go forward and it
9 gets legally challenged and under that current statute
10 it gets overturned, I still think we should proceed --
11 DR. BAEPLER: And help us get it changed.
12 MR. LEGARZA: We haven't had any yet.
13 DR. BAEPLER: We have one pretty good one in
14 Las Vegas.
15 MR. QUINN: There are a couple other
16 provisions -- and I'm going to take these to heart --
17 because there are a couple other provisions where if a
18 doctor engages in disreputable conduct, that is one
19 specific grounds for discipline, disreputable conduct.
20 So, you know, that's an express ground.
21 PRESIDENT HUG-ENGLISH: Dr. Lubritz?
22 DR. LUBRITZ: I would like to go on the record
23 and say I spoke out of turn. Obviously if the judge
24 tells us to do something then obviously we have to
25 listen to the judge.
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1 PRESIDENT HUG-ENGLISH: Okay. Thank you.
2 Okay. Is there anything else?
3 MR. QUINN: Nothing else. Thank you.
4 PRESIDENT HUG-ENGLISH: Do we need a break?
5 Let's take a five-minute break.
6 (Recess was taken.)
7 PRESIDENT HUG-ENGLISH: Moving along. We have
8 just a couple more things on this agenda, and then we
9 will get started on our appearances.
10 The next is actually consideration for a
11 request by the Nevada State Medical Association for an
12 appointment of a board member to act as a liaison. And
13 you saw the letter that was included by Dr. Williamson.
14 Oh, sorry. I didn't have my button on.
15 We are talking about agenda item number 19
16 about appointing a liaison member to the MNSA, and I
17 certainly would encourage this.
18 I think the more communication we can do as a
19 board to the medical society helps in communication of
20 what we are doing and also letting us know what some of
21 their issues are. And I would certainly accept anybody
22 who is willing to volunteer to do that.
23 DR. BAEPLER: They specified they wanted an
24 M.D. member.
25 Where do they typically meet? Which end of
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1 state?
2 PRESIDENT HUG-ENGLISH: Well, I think this
3 state meeting is in Vegas. I don't know whether they
4 alternate or not.
5 DR. HAVENS: I can answer that. The meetings
6 occur simultaneously in the north and the south, and it
7 is teleconferenced just by audio. So you can attend MSA
8 meetings in Las Vegas and all of them are
9 teleconferenced between the two places.
10 There is an annual meeting that is at the
11 Wig-Wam Hotel in Litchfield, Arizona coming up if you
12 want to attend that. That's a trip out of the State.
13 But the normal meetings they have executive
14 counsel or the executive board are at both ends of the
15 state simultaneously.
16 DR. BAEPLER: So the geography means nothing
17 here.
18 PRESIDENT HUG-ENGLISH: Since Robin and I are
19 going to be leaving the board, I don't think it's
20 appropriate for us. So there are really very few of us
21 who'll be left, but is there anybody willing to take
22 that on or should we appoint Joel since he is absent.
23 DR. MONTOYA: I can attend some of the
24 meetings.
25 PRESIDENT HUG-ENGLISH: So Dr. Montoya has
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1 graciously volunteered. It may be a rotating member.
2 I'm not sure it always has to be the same person. I
3 think it would be good to have a representative from the
4 board and appreciate the letter that Dr. Williamson
5 sent.
6 So we'll have you as our appointee from now.
7 And if that changes, we can certainly appoint someone
8 else. Thank you.
9 There was a request to reschedule the December
10 board meeting. That was Joel.
11 How about ratifying the licenses that were
12 under agenda item number 21. These are ratifications of
13 licenses that we issued and reinstatements of licensure
14 or changes.
15 DR. BAEPLER: I move that we ratify them.
16 MS. KIRCH: Second.
17 PRESIDENT HUG-ENGLISH: There is a motion and
18 a second to ratify the licensures. All in favor?
19 THE BOARD: Aye.
20 PRESIDENT HUG-ENGLISH: Opposed? Chair votes
21 in favor of the motion. And the motion carries.
22 So I think the only other agenda item we have
23 is -- Larry, do you know what the issue was for
24 changing the meeting date?
25 MR. LESSLY: Joel had a conflict.
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1 DR. BAEPLER: My sense is that the malpractice
2 review committee is working very well. You are handling
3 a significant number of cases.
4 PRESIDENT HUG-ENGLISH: Yes, we are. And,
5 actually, thank you, Don. I didn't see that under the
6 agenda item.
7 I think it has been helpful. And we actually
8 were able to make decisions on, I think, eight or nine
9 in the last which, you know, saves at least a couple
10 hours at or nine appearances.
11 So I think it is working. I think it is
12 worthwhile to continue, and we will keep doing it.
13 MR. LESSLY: We can do 23.
14 PRESIDENT HUG-ENGLISH: Okay.
15 MR. LESSLY: Matters for future agenda. The
16 June meeting we will have staff evaluations and salary
17 considerations, legislation, and election of officers.
18 PRESIDENT HUG-ENGLISH: Okay. Any other
19 matters for future agenda that anybody else wants to see
20 on for June?
21 PRESIDENT HUG-ENGLISH: Okay.
22 Joel, we were on agenda item 20 about
23 rescheduling the December meeting. I think that was the
24 meeting you had asked --
25 MR. LESSLY: And they turned it down.
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1 DR. LUBRITZ: No. I just want to say if it
2 was inconvenient, fine. And if it's not an
3 inconvenience, if it could be moved a week.
4 PRESIDENT HUG-ENGLISH: Were you asking it be
5 moved to --
6 DR. LUBRITZ: I didn't care.
7 PRESIDENT HUG-ENGLISH: Just not that
8 particular day?
9 DR. LUBRITZ: That particular day. And if
10 it's a problem, then no big deal. I will be here for
11 what I can and what I can't be here --
12 MS. KIRCH: I have a conflict the following
13 week, and now you are starting to get close to
14 Christmas.
15 DR. BAEPLER: Move it up a week. That's
16 probably Thanksgiving.
17 PRESIDENT HUG-ENGLISH: That's part of the
18 problem.
19 DR. LUBRITZ: I will withdraw the request.
20 PRESIDENT HUG-ENGLISH: I'm not going to be
21 here.
22 DR. LUBRITZ: I will withdraw the request.
23 That is very insignificant.
24 PRESIDENT HUG-ENGLISH: All right. Then I
25 think we are ready for our appearances.
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1 (Whereupon the remaining proceedings were
2 held in closed session.)
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1 STATE OF NEVADA, )
) ss.
2 COUNTY OF WASHOE. )
3
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 23rd day of March,
21 2004.
22 ___________________________
LISA A. YOUNG, CCR #353
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PEGGY HOOGS & ASSOCIATES (775) 327-4460