Pharmacists, physicians and nurses: Is your state licensing Board friend or foe?

Posted on August 9, 2016 by - Licensure

To report or not report: Discipline versus a Letter of Appreciation

Reporting troubling information to your licensing Board and navigating the subsequent investigation is seldom one’s first choice, but it can be done well, and it may spare you from discipline later. You might even discover that your licensing Board is your friend and ally. To illustrate this discussion, I am using two cases involving pharmacists and the Oregon Board of Pharmacy, but the same principle can apply to nurses before the Oregon State Board of Nursing and physicians before the Oregon Medical Board.

Two pharmacy cases that make the point

In one case, the pharmacist in charge (PIC) was managing a pharmacy technician whose qualifications to hold her technician’s license were suspect. The PIC did not report the technician, believing the Board of Pharmacy “would not have done anything” to help, since the Board licensed her in the first place. As he would later learn, however, had he made an appropriate report to the Board, he would have satisfied his professional obligation to report, while simultaneously gaining the Board’s participation in the problem, relieving him of much responsibility. A simple report to the Board would have spared him the grief that followed as he sought to manage a problem he could not manage, and should have instead reported. In the end, his failure to report the technician, and to work collaboratively with his licensing Board, proved a costly lesson: discipline.

By way of comparison, in an another case, the PIC discovered an ongoing drug theft that occurred on his watch, a drug theft that perhaps should have been discovered sooner. Nonetheless, his drug inventory reconciliations uncovered the drug loss and, through his extraordinary efforts, he identified the technician responsible for the drug theft. His reports to the Oregon Board of Pharmacy and the Drug Enforcement Administration (DEA) were timely, and his participation with the Board during the investigation was exemplary. In the end, he was not disciplined, but instead received a letter of appreciation from the Oregon Board of Pharmacy.

The moral of the story

The crucial point not to be missed is that these two pharmacists could have reversed their fortunes (good or bad) by simply reversing their decisions to report to the Board (or not to report). I can assure you that the pharmacist that reported to the Board in the second example above (involving the drug theft), and then experienced the benefit of reporting, will do so again, should the need arise. As for the other pharmacist, the one that chose not to report his technician’s lack of qualifications, and faced the consequences, next time, he too will report to the Board.

Physician wins! Oregon Court of Appeals reverses Medical Board in my client’s favor

Posted on August 5, 2016 by - Appellate, Licensure

This is a case I took up on appeal for another lawyer, and won. In this case, the Oregon Medical Board revoked a physician’s medical license by missapplication of complex procedural rules. In a unanimous decision, however, the Oregon Court of Appeals reversed the Oregon Medical Board in my client’s favor. See Yankee v. Oregon Medical Board, 280 Or App 1 (August 3, 2016) (remanding for further proceedings).

Appeals against the Oregon Medical Board are difficult to win

On appeal to the Oregon Court of Appeals, I argued that the Oregon Medical Board erred when it denied my client’s motion to reschedule his hearing, and revoked his medical license, without first holding a hearing on his motion before an Administrative Law Judge (ALJ), as required by administrative rule. The Oregon Court of Appeals agreed, and reversed the Oregon Medical Board, remanding the case for further proceedings.

This appeal was won on procedural grounds and, as experienced appellate lawyers know, this type of appeal can be difficult to win. I argued this case to the Oregon Court of Appeals in February of 2015, but the court did not decide the case until August of 2016, 18 months later, suggesting that the Court of Appeals needed significant time to decide this troubling case.

The Court of Appeals’ ruling: The Oregon Medical Board must follow prescribed procedure

The holding in this case is simple: The Oregon Medical Board must follow “prescribed procedure” when seeking to revoke a physician’s license:

“Having concluded that the [Oregon Medical] board procedurally erred when it did not provide [Dr. Yankee] with a hearing before the ALJ, we must remand this matter for further proceedings if “the fairness of the proceedings or the correctness of the action may have been impaired” by that “failure to follow prescribed procedure.” ORS 183.482(7). Here, the fairness of the proceedings may have been impaired. [Dr. Yankee] was entitled to have a hearing before a neutral ALJ [Administrative Law Judge] on the reasons for his not appearing once the [Oregon Medical] board disputed the facts articulated by [Dr. Yankee]. Instead, the [Oregon Medical] board resolved those disputed factual issues in its own favor. Accordingly, we reverse and remand for further proceedings.”

See Yankee v. Oregon Medical Board, 280 Or App 1, 6 (August 3, 2016) (underscore added).

Marijuana, the practice of medicine, and the Oregon Medical Board

Posted on July 18, 2016 by - Licensure

Under federal law, marijuana is a Schedule I banned substance, meaning that without a research permit or exception, it cannot be used or prescribed for any purpose. In recent years, however, a number of states, including Oregon, have “legalized” marijuana for medical purposes (and in fewer states, for recreational use). For a number of reasons, the Drug Enforcement Administration (DEA) has abandoned the enforcement of the federal drug laws as they pertain to the medical and recreational use of marijuana in those states that have declared it legal. Based upon my experience, however, I urge you not to become complacent when recommending or approving marijuana for medical use. Here’s why.

The Oregon Health Authority versus the Oregon Medical Board or: “it’s still the practice of medicine, dude.”

The Oregon Health Authority (OHA) sets out the statutes and rules applicable to the Oregon Medical Marijuana Program (OMMP) and further offers a wealth of relevant information and advice. See, e.g., http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/MedicalMarijuanaProgram/Pages/legal.aspx. Be forewarned, however, that compliance with the OMMP will not necessarily satisfy the Oregon Medical Board when there is a complaint or discrepancy involving professional protocols or the standard of care. As one investigator recently put it, “it’s still the practice of medicine, dude.” In other words, it may be legal, but more may be required of you.

Do not confuse “legality” with the standard of care

The State of Oregon may have legalized marijuana, but the Oregon Medical Board regulates the practice of medicine and is particularly concerned with how you meet the applicable standard of care and/or other professional protocols or commitments that may apply in any given situation. Stated differently, in Oregon, the OMMP establishes the circumstances under which medical marijuana is legal, but the medical profession adds another layer – the standard of care – and it is the Oregon Medical Board that will ensure that the standard of care is met. The fact that you may be recommending medical marijuana consistent with the OMMP will not much satisfy the Oregon Medical Board if the standard of care requires more.

Licensure applications and the dreaded “yes questions”

Posted on July 12, 2016 by - Licensure

I recently discussed a few of the many mandatory reporting obligations imposed on physicians and nurses. Today I want to discuss the “dreaded yes questions.”

A dreaded yes question is a question you want to answer “no,” but truthfulness requires that you answer “yes,” hence the question is dreaded.

For example, last week, a physician asked me how to answer a boilerplate question found on many residency applications, and a nurse asked me to help her report a drug and alcohol-related arrest on her renewal application. The question on the residency application asks, “Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?” To answer this question, one would need to know what kind of things limit the ability to be licensed, or to gain hospital privileges. Without relevant experience, this question will be difficult to answer. The renewal question for the nurse, involving drug and alcohol-related arrest and her renewal application, was much more straight forward.

License renewal applications and DUII arrests and convictions

I am often asked about the need to report driving under the influence of intoxicants (drunk driving or DUII) arrests and convictions, and less often about the need to report a drunk driving arrest that did not result in a conviction. One recent case illustrates the complexity of the various mandatory reporting requirements. I represented a physician who had been arrested, but was not convicted, for driving under the influence of intoxicants. The physician was licensed in three states. The phrasing of the question on the renewal applications was all important, and it differed state-by-state. One state required a conviction to be reported, but not a mere arrest. Another state required that the arrest be reported, regardless of whether there had been a conviction. The third state was a close-call case.

What to do with close-call questions on license renewal applications

Occasionally, the facts and circumstances, combined with the phrasing of the question on the renewal application, will make the answer too close to call with desired certainty. Is these cases, an experienced healthcare defense attorney can advise you on the risks of not reporting, versus the benefits of reporting to ensure compliance with your mandatory reporting requirements. An experienced healthcare defense attorney can also do something you should not, and that is to make a call to the right person at your licensing Board, in an effort to learn more, but without disclosing your name.

One final caveat about the failure to report

In my experience, those choosing not to report a reportable incident deeply regret that decision once the incident comes to the attention of their licensing Board. The failure to report simply adds another layer to the investigation and exposes you to additional scrutiny because your veracity is now in question.

 

Licensure and mandatory reporting requirements

Posted on July 9, 2016 by - Licensure

As a licensed healthcare provider, you have mandatory reporting requirements

Upon your initial application for licensure, you will be required to answer a series of questions designed to disclose past conduct that may have an adverse impact on your ability to practice your profession. Thereafter, you have a continuing obligation to report specified incidents to your licensing Board, often within 10 days of the occurrence of the incident, or at the time of your license renewal.

The reporting laws are complex and nuanced. Although it is tempting to rationalize why the incident in question need not be reported, this is often a mistake, because the failure to report a reportable incident is itself a violation. Before you report, or decide not to report, you are encouraged to seek experienced legal counsel, to determine first if a report is in fact and law required to be made, and second, how best to make the report to minimize any adverse impact on you or your license.

For physicians, incidents subject to mandatory reporting include, but are not limited to, the following:

  • Criminal convictions or felony arrests;
  • Discipline by other state licensing boards;
  • Loss of privileges, withdrawal, resignation, or limitation of practice; and
  • Medical incompetence, unprofessional or dishonorable conduct, or physical incapacity

To get started, physicians should consult the following reporting statutes and agency rule:

For nurses, incidents subject to mandatory reporting include, but are not limited to, the following:

  • A nurse imposter;
  • Practicing nursing without a license;
  • Arrest or conviction of a crime which relates adversely to the practice of nursing or the ability to safely practice nursing;
  • Dismissal from employment due to unsafe practice or conduct derogatory to the standards of nursing;
  • Client abuse;
  • Conduct derogatory to the standards of nursing as defined;
  • Any violation of a disciplinary sanction imposed on the licensee by the Board of Nursing;
  • Failure of a nurse not licensed in Oregon and hired to meet a temporary staffing shortage to apply for Oregon licensure by the day the nurse is placed on staff;
  • Substance abuse as defined in ORS 678.111(e); and
  • Any other cause for discipline as defined in ORS 678.111.

To get stated, RNs and LPNs should consult the following chapter:

Mandatory reporting can be assisted by a healthcare defense attorney

As you can see, mandatory reporting can present complicated questions. I am frequently asked, “do I have the report this, and if so, how soon?” My initial reaction is usually accurate, but in almost all cases, I will look it up myself. The reason I look it up is that as a healthcare defense attorney, I represent too many professions (physicians, pharmacists, nurses, acupuncturists, etc.), and there are too many reporting requirements to commit it all to memory. Also, in close-call cases, accurate reporting requires some analysis, or you risk under-reporting or over-reporting. Under reporting (i.e., failing to report) exposes you to discipline and other problems with your licensing Board or other important institutions, while over-reporting (i.e., unnecessary reporting) exposes you to a process most licensed professionals prefer to avoid. So again, before you report (or decide not to), you are encouraged to seek competent legal counsel, to determine first if a report is in fact and law required to be made, and second, how best to make the report to minimize any adverse impact on you or your license.

Defending physicians who prescribe opioids

Posted on June 21, 2016 by - DEA Prosecutions, Licensure

Experiences of a healthcare defense attorney

I have defended physicians, pharmacists, and prescribing nurses from prescription drug charges by the Drug Enforcement Administration (DEA) long enough that I well remember the following events:

  • the short-lived FAQ’s briefly posted to the DEA’s website (the FAQs were removed from the DEA’s website because pain advocates and defense lawyers cited the favorable FAQ’s in the courtroom);
  • the “Quick Reference Card,” (the Quick Reference Card was a highly formatted legal crib sheet used by prosecuting attorneys in the courtroom, but it was discontinued due to its misstatements of the law of drug diversion);
  • the argument that opioid dosing is to be determined “titrating to full function” (finding the optimal dose to improve daily functioning – the best analgesia with the fewest side effects; but was this ever the standard?); and
  • the day in 2007 that Purdue Pharma pleaded guilty, and paid a $630 million settlement, against federal charges that it misled healthcare providers about the risks of OxyContin.

Overtime, I have accumulated the type of experience that causes me to offer cautious advice to prescribing physicians treating chronic pain with opioids. Cautious advice will sometimes disappoint a prescribing physician, and will certainly disappoint the physician’s patient seeking more aggressive treatment. I am, however, a healthcare defense attorney, and my experience includes keeping physicians out of prison, and winning their release from prison once they are there. In other words, my goal is to keep you out of trouble and cautious advice furthers that goal.

The pendulum has swung: Treat chronic pain cautiously

It is based on my experience that I can assure prescribing physicians and nurses that the treatment of chronic pain with opioids exposes you to scrutiny by the Oregon Medical Board, the Oregon State Board of Nursing, and the Drug Enforcement Administration. Based upon two recent experiences, I also detect that the pendulum has swung, and the emerging practice standards and protocols governing the treatment of chronic pain with opioids are more detailed than ever.

These Oregon Medical Board and OHSU publications may serve you well

I am a healthcare defense attorney, not a healthcare provider, so my opinion is informed by others, and at this point my opinion on this subject is not fully informed. Nonetheless, if you are a prescribing physician or nurse treating chronic pain with opioids, and you come under scrutiny by the Oregon Medical Board, the Oregon State Board of Nursing, and/or the Drug Enforcement Administration, you may be well served if you have followed these practice guidelines made available by the Oregon Medical Board and Oregon Health & Science University:

 

Defending a licensing Board complaint during the first few days

Posted on June 17, 2016 by - Licensure

You’re a physician, pharmacist, or nurse, and you just learned a complaint has been filed against you with the Oregon Medical Board, the Oregon Board of Pharmacy, or the Oregon State Board of Nursing. Now what?

Stop, collect your thoughts, establish the first deadline

If you just received word-of-mouth notice, or a letter from your licensing Board, time is momentarily on your side, so take advantage of it. Avoid knee jerk reactions. Whatever you do, do not call your licensing Board or the investigator that sent you a letter. You’re not ready. You’re too emotionally involved. Instead, establish the first deadline. Get time under control. Stop. Think.

Don’t assume you know the substance of the Board complaint

It is only natural to speculate about the nature of the complaint. The tendency is to speculate based upon what you know, and then rationalize why the Board complaint is unfounded. The problem with this approach is that your knowledge of the complaint is most often limited, and your conclusions may therefore be wrong. This is no way to plan your defense.

Retain a healthcare defense attorney with experience defending licenses for physicians, pharmacists, and nurses

The better approach is to have a healthcare defense attorney contact the investigator, to learn about the complaint and to further discover what most concerns the investigator. Be aware that this call to your investigator is not a call you can make well, because once the investigator explains the basis of the complaint, a reaction will expected of you. It’s only natural; this is the way conversation works. You, however, will not be prepared to answer. Yet there you are, on the phone with the investigator, your mind racing, wondering how to respond to fill the silence. This is no time to be experimenting with answers. Again, the better approach is to have an experienced healthcare defense attorney contact the investigator. Your attorney will then share this information with you in a private setting where the issues and concerns may be thoughtfully explored, without risk to you. Remember, your best answer to the complaint will take some time and work to marshal; it will not emerge extemporaneously during a first phone call with the investigator. Have your attorney make that first call instead.

Don’t blame others until you have explained your role

If others were involved in the circumstances setting up the Board complaint, do not blame them, at least not at first. For some, placing blame where it belongs is a strong personal instinct. If others were involved, they will be investigated or interviewed too. When it is your turn, the investigator wants to understand your role in the circumstances behind the complaint and, until your role is satisfactorily understood, blaming others will come off as evasive, uncooperative, and non-responsive. Don’t make this mistake. An experienced healthcare defense attorney will help you avoid this mistake. And remember, if your role in the complaint was truly small and non-contributing, it will not take long to explain, and a good explanation will reference the participation of others, from which the investigator will draw all appropriate conclusions. In the context of a medical Board investigation, blaming others requires a deft touch.

Two “red flags” when interviewing a licensing lawyer to defend your medical license

Posted on June 10, 2016 by - Licensure

Red flag #1: Blaming the licensing Board’s investigator

Earlier this year, a practitioner hired me as her second lawyer, and I took over the representation of her case.  Later, after much of our work had been completed, she expressed surprise at how helpful the investigator had been.  When I asked her why she was surprised, she explained that her first lawyer blamed the investigator, saying something like, “Oh, you have Jane Doe for an investigator, you’re in trouble.”  That was unfortunate.  I have worked with the same investigator and find her easy to work with. More importantly, I regularly represent nurses, pharmacists and physicians before the Oregon State Board of Nursing, the Oregon Board of Pharmacy, and the Oregon Medical Board, and there has never been a reason to blame the investigator.  It is my opinion that if a lawyer you interview blames the investigator, keep interviewing lawyers until you find one that works well with investigators.  Your interests will be better served in the short and long run.

Red flag #2: Utilizing a litigious approach with an investigator

Last year I had a chance to ask an investigator what she thought of the relatively small group of lawyers that routinely appear before her licensing Board.  I was surprised to learn that some used a tough approach, keeping communications short, and often implying that a contested case hearing (litigation) would be necessary when, in fact, they seldom are.  Needless to say, these lawyers, due to their uncooperative reputations, were not favored by the investigators.  As my record will demonstrate, I am willing to advance tough litigation in defense of physicians, pharmacists, and nurses, but litigation must be reserved for the right circumstances.

More importantly, consider the disadvantage you may suffer because of your lawyer’s “tough talk.”  For example, throughout the course of a licensing Board’s investigation, much information must be exchanged, and any alleged practice discrepancy prompting the complaint against you must be carefully evaluated.  Consider also that you will most likely be interviewed by the investigator, and much of the work of the interview can be accomplished between your lawyer and the investigator, sparing you much grief.  Whatever the cause of the complaint, solutions must be negotiated.  Ultimately, the investigator will write the summary of your case, including recommendations, that will become the basis of the Board’s decision against your medical license.  For all these reasons, it is my opinion that a cooperative and professional relationship between your lawyer and your licensing Board’s investigator will lead to the most efficient and complete exchange of information, and the best resolution of your case.  Along the way, you will be better informed too.

Do not dismiss the power of your licensing Board

Posted on June 8, 2016 by - Licensure

I have won significant federal court litigation defending health care providers, including physicians and pharmacists.  Knowing this, a health care provider growing weary of defending against his or her licensing Board will occasionally ask why I can’t do more in his or her case.  For example, one physician wanted me to sue the Oregon Board of Medicine in “a real court of law,” and one nurse asked whether I could obtain a Temporary Restraining Order (TRO) against the Oregon State Board of Nursing.  The answer is almost always “no.”  Let me explain why.

The 50 states regulate medical licensing and practice standards

In our State-Federal scheme of government, the power to regulate medical practice and licensing is reserved to the 50 states.  Admittedly, there is federal “overlay,” but still, when it comes to ensuring safe medical practice through the licensing of physicians, pharmacists, nurses, that role and power belongs to the states.

The 50 states exercise their “power” through state agencies

You may recall from civics classes that state and federal power is spread across three branches of government, the Legislative, the Judicial, and the Executive branches.  The Executive branch of state government is headed by the Governor, and the bulk of any state’s work is accomplished through a multitude of state agencies belonging to the executive branch.

Your licensing Board is a state agency

Whether you are a physician, pharmacist, or nurse, your licensing Board is a state agency, specifically empowered to ensure the safe practice of your profession (public safety) and the competency of each individual practitioner.

What you need to know: Respect your licensing Board

So, when the physician wanted me to sue the Oregon Board of Medicine in “a real court of law,” and the nurse asked whether I could obtain a TRO against the Oregon State Board of Nursing, you now know why the answer was “no.”  Even when the complaint against you is wrong, or the licensing Board is wrong, the licensing Board is nonetheless fulfilling its role as a state agency regulating your profession.  It is true that in some cases there may be an appeal to a state court (this happens occasionally) and, in the exceedingly rare case, an argument for a restraining order from a trial court (this has happened only once in my career), but this is not where you start.  You start with the agency – i.e., your state licensing Board – because your state licensing Board is not only empowered to regulate your profession, it has the most power to do so, and your interests will be best served by taking that power seriously.

More on how to “pass” (or fail) your licensing Board interview

Posted on May 30, 2016 by - Licensure

Whether you are being investigated by the Oregon State Board of Nursing (OSBN), the Oregon Medical Board (OMB), or the Drug Enforcement Administration (DEA), your success during your interview is key to the successful resolution of the investigation.  Today I will share with you the experience of three clients – a nurse, a physician, and a dentist – all of whom went to interview within a 14-day span this month.  Two “passed.”  One “failed.”  Let my tell you why.

The nurse and the Oregon State Board of Nursing (OSBN)

Earlier this year I undertook the representation of a well-qualified and experienced nurse under investigation by the Oregon State Board of Nursing (OSBN).  She went to interview this month.  At one hour and 45 minutes, her interview was long, and seemed even longer with four of us in a room that was too small and too hot.  The interview was led by the OSBN nurse investigator and assisted by an OSBN advanced practice nurse, with my client the focus of attention.

The first hour of the interview was necessary to get at the core issues in this unusually complex case.  The OSBN’s investigator and advanced practice nurse were well prepared (aren’t they always?).  My client was also well prepared, however.

As we passed through the first hour of the interview, I was impressed by the depth of the discussion and by my client’s answers.  I privately marveled at how few members of the public will ever appreciate how carefully the practice of nursing is regulated in Oregon.  My client was subjected to questions for an hour and 45 minutes, by two investigators, and her interview had the tone of a thoughtful discussion.  She passed the test.  The case isn’t over, but my client did a stellar job, and representing her that day was professionally rewarding.

The dentist and the Drug Enforcement Administration (DEA)

I also prepared a dentist for an interview this month before the Drug Enforcement Administration (DEA). In this case, the dentist sought reinstatement of his DEA Registration, earlier surrendered.

In a December 7, 2015 post, I explained that in the right circumstances, reinstatement of a surrendered or revoked DEA Registration is possible.  These can be tough interviews, however, because in cases where a DEA Registration has been surrendered or revoked, there are usually a few “sensitive” issues.  Also, the interviews are conducted by DEA Drug Diversion Agents and, in my experience, there are always two of them.

This interview was nonetheless a success.  By the end of the interview, my client was advised he would have his DEA Registration back in four to six weeks, with a few temporary, common sense restrictions, but nothing that will interfere with his practice.  It doesn’t get much better than that!

The physician and the Oregon Medical Board (OMB)

In the same 14-day span this month, I was hired by a physician but, unfortunately, her interview occurred the week before I was hired, and she went alone, unprepared, and unrepresented.  She “failed.”  Let’s consider what my client was up against.  By the time of her interview at the Oregon Medical Board, the Board’s investigator, the Board’s Investigative Committee’s (IC), and the Board’s expert, had all finished their work.  Counting the Board’s investigator, the Board’s expert, and the four members of the Investigative Committee, six people were prepared to interview my client that day.  If you find yourself facing a Board interview, ask yourself the following questions:

  • What have you done to prepare?
  • Who has given you legal advice?
  • Who has prepared you?

If you cannot answer these simple questions in a reassuring manner (without rationalizations or excuses), you are not ready for your interview.  As I have said many times before, an interview with your licensing Board is no place to show up and see what happens.

The moral of the story

In this case, there is little doubt in my mind that this physician should have passed her interview, had she been ready.  But she wasn’t ready.  Don’t let this happen to you.  An experienced healthcare defense attorney will help you prepare for your interview.