ARIZONA MEDICAL BOARD FISCAL YEAR 2007-2008 ANNUAL REPORT 9545 East Doubletree Ranch Road Scottsdale, Arizona 85258 (480) 551-2700 or toll-free (877) 255-2212 www.azmd.gov TABLE OF CONTENTS Letter to the Governor, Janet Napolitano …………………………………………..……….. Page 2 . ARIZONA MEDICAL BOARD Board Membership ………………………………………………………………………….. Pages 3-6 Board Accomplishments…….……………………………………………………………… Page 7 Licensing ……………………………………………………………………………...……… Page 8 Regulation ………….………………………………………………………………………… Pages 9-10 Page 1 LETTER TO THE GOVERNOR JANET NAPOLITANO Governor Janet Napolitano Members of the Arizona Medical Board William R. Martin, III, M.D. Chair/Physician Member Douglas D. Lee, M.D. Vice Chair/Physician Member Dona Pardo, Ph.D., R.N. Secretary/Public Member/R.N. Robert P. Goldfarb, M.D., FACS Physician Member Patricia R. J. Griffen Public Member Andrea Ibañez Public Member Ram R. Krishna, M.D. Physician Member Todd A. Lefkowitz, M.D. Physician Member Lorraine L. Mackstaller, M.D. Physician Member Paul M. Petelin, Sr., M.D. Physician Member Germaine Proulx Public Member Amy J. Schneider, M.D., FACOG Physician Member Executive Staff Lisa Wynn Executive Director Amanda J. Diehl, M.P.A., C.P.M. Deputy Executive Director Roger Downey Media Relations Officer D ear Governor Napolitano: On behalf of the Arizona Medical Board, I submit to you our 2008 Annual Report. As healthcare continues to evolve, the Board maintained its position at the forefront of efforts to protect the public through the regulation of physicians. At the same time, it provided its licensees with appropriate guidance to practice medicine safely and in accordance with the Medical Practice Act. Your Regulatory Review Council helped the Board make office-based surgical procedures safer by approving new rules that provide physicians with the minimum standards the Board expects in equipment, training and planning. While no state limits a doctor’s scope of practice, the Board is among the first to develop guidelines for physicians who decide to pursue new areas of medical practice or use new technologies even though they have no formal training in those areas. These guidelines are meant to assist the physician in identifying what he or she needs to consider before changing his or her practice. With no end in sight to an expanding shortage of physicians, the role of Physician Assistants has become more important in providing the availability of quality healthcare to Arizonans. The Board recognized that improving the supervision of PAs required a cooperative effort with the Arizona Regulatory Board of Physician Assistants. So, together, the Boards developed guidelines that both physicians and PAs can follow to ensure patient safety. The Arizona Medical Board remains committed to its mission—the protection of public health and safety. Sincerely, Lisa Wynn Executive Director Page 2 ARIZONA MEDICAL BOARD MEMBERSHIP William R. Martin, III, M.D., the Board’s Chair, is a Board-certified, fellowship trained Orthopedic Surgeon at Copper State Orthopedics, Ltd., Phoenix, Arizona. In addition to his busy private practice, he helps to provide Orthopedic services for Children’s Rehabilitative Services (CRS), and for the poor and the medically indigent populations both in the inner city and on Native American Indian Reservations. Dr. Martin is also the medical director of Urgent Care+, LLC, Phoenix, Arizona. Dr. Martin is a member of the American Academy of Orthopaedic Surgeons (AAOS) and has a dual appointment on the Academy’s Diversity Advisory Board and on the Council on Advocacy. Dr. Martin is a lifetime member of the National Association for the Advancement of Colored People. He is a member of the American Medical Association, the Arizona Medical Association, and the Arizona Orthopaedic Association. Dr. Martin received his medical degree from Loyola University of Chicago in Maywood, Illinois. Douglas D. Lee, M.D., the Board’s Vice-Chair, is a Board-certified Anesthesiologist practicing in Flagstaff, Arizona. He graduated from the University of Arizona School of Medicine, completed an internship at the National Naval Medical Center in Bethesda, Maryland and a residency at the Naval Regional Medical Center in San Diego, California. From 1980 to 1981, Dr. Lee was a United States Marine General Medical Officer in Okinawa, Japan, and he was also a reservist called to serve in the Desert Shield/Desert Storm 1st Marine Division from 1990 to 1991. In addition to his professional experience, Dr. Lee is a member of the Arizona Society of Anesthesiologists and a member of the American Board of Anesthesiologists. He previously served as the Chairman of Anesthesia for the Flagstaff Medical Center (FMC), President of the FMC Medical Staff, and President of the Arizona Society of Anesthesiologists. He currently serves as a Staff Anesthesiologist at FMC and Managing Partner of Forest County Anesthesia, PC. He is also a Board Member of the FMC Ambulatory Surgery Center and a member of the FMC Credentials Committee. Dona Pardo, R.N., Ph.D., the Board’s Secretary, is a public member and a registered nurse. Dr. Pardo has over 30 years experience in nursing education and has taught in diploma, associate degree, baccalaureate degree and continuing education programs. She retired from the University of Arizona after 21 years of service during which she taught baccalaureate nursing students, headed the Continuing Education program in the College of Nursing, and just prior to retirement was the Administrator, Continuing Education for the Arizona Health Sciences Center. In that post, she was responsible for Continuing Education for physicians and nurses. Dr. Pardo is 2nd Vice-President of the Board of Directors for Compass Healthcare, and founding Foundation Director and current Treasurer for Tucson Nurses Week Foundation. Dr. Pardo earned her master’s degree in nursing from the University of Texas Health Sciences Center at San Antonio and holds a doctorate in higher education from the University of Arizona. Page 3 ARIZONA MEDICAL BOARD MEMBERSHIP Robert P. Goldfarb, M.D., FACS, graduated from Tulane University, School of Medicine and practices in a Tucson, Arizona Neurosurgery-Neurology specialty group practice and serves as President of the group practice. Dr. Goldfarb also is the Neurosurgical Consultant to the University of Arizona Athletic Teams and is a Clinical Associate Professor in the Department of Surgery, College of Medicine at the University of Arizona. Dr. Goldfarb completed his Internship at Michael Reese Hospital and Medical Center in Chicago and his Residency in Neurological Surgery at the University of Illinois Hospitals and PresbyterianSt. Luke’s Hospital in Chicago. He is certified by the American Board of Neurological Surgery and is a Fellow of the American College of Surgeons. He has previously served as Chief of the Medical Staff at Tucson Medical Center and is currently a Member of the Board of Trustees at El Dorado Hospital and a member of several professional societies including the American Association of Neurological Surgeons (Harvey Cushing Society), Congress of Neurological Surgeons, American Medical Association, North American Spine Society, Arizona Medical Association, and the Pima County Medical Society. Patricia R. J. Griffen, a public member, is the founding Executive Director of Against Abuse, Inc., established in October 1981 to provide domestic violence and child abuse shelter services to the citizens of Pinal County. She received her Bachelor of Science Degree in Social Administration from the University of Arizona. Ms. Griffen has more than 35 years experience in the field of private, non-profit management. This includes her role as a founding member of Arizona Coalition Against Domestic Violence and formerly serving as a member of the organization’s Board of Directors. She is a state and local speaker on a wide range of domestic violence and child abuse issues. Ms. Griffen is the secretary of the Pinal County Victim Compensation Program, the Chair of the City of Casa Grande Personnel Advisory Board, and the Chair of the Desert Pavilion Advisory Board. Andrea Ibañez, a public member, is the Deputy Director of the Department of Neighborhood Resources for the City of Tucson and supervises the daily work of the Neighborhoods and Administration Division. Before taking that post, Ms. Ibañez served as a Project Manager in the Tucson City Manager’s Office. She has also worked as an Interim Tucson Court Commissioner and as a Youth and Family Coordinator for the City. Ms. Ibañez is a member of the University of Arizona Hispanic Alumni Association, the Pima County Children’s Action Alliance Advisory Board, the Hispanic Professional Action Committee, and the Arizona City County Managers Association. Ms. Ibañez has a masters degree from Syracuse University and a Certificate in Public Policy and Management from the Eller College of Management at the University of Arizona. Page 4 ARIZONA MEDICAL BOARD MEMBERSHIP Ram R. Krishna, M.D., is an Orthopedic Surgeon who is currently in private practice in Yuma and was formerly the chief of surgery at Yuma Regional Medical Center. Dr. Krishna served as chair of the Yuma Regional Medical Center Board of Trustees and as president of the Yuma County Medical Society. Currently, he is a member of the Arizona Orthopedic Society and the Arizona Medical Association. Dr. Krishna was awarded the Arizona Medical Association’s Distinguished Service Award in 2000 for his exceptional work in the community. Dr. Krishna has been elected to serve as the representative of the Federation of State Medical Boards on the Board of Directors for the Educational Commission for Foreign Medical Graduates. He obtained his medical degree from Bangalore University Medical College in Bangalore, India. He did his internship, a one-year residency in general surgery and a four-year residency in orthopedics at the University of Massachusetts Medical Center. Todd A. Lefkowitz, M.D., is a Boardcertified Ophthalmologist and the Medical and Surgical Director with Nationwide Vision Group in Phoenix. He has had an Arizona medical license since 1983 when he became Chief of Ophthalmology at Luke Air Force Base. tive Surgeons. Prior to his appointment to a fiveyear term on the Medical Board, he reviewed cases as one of the Board’s Outside Medical Consultants. Dr. Lefkowitz is a former Executive Committee member of Physicians for the Phoenix Symphony. He has written two books and in 1991 was a three-time “Jeopardy” champion on the long-running TV quiz show. Lorraine Mackstaller, M.D., is Board certified in Internal Medicine and specializes in cardiovascular disease. She began her medical career as a Registered Nurse at St. Joseph’s Hospital in Phoenix, and then thirty years later earned her M.D. at the University of Arizona in Tucson. She performed her residency in internal medicine at the University of Arizona and is currently on staff at the Sarver Heart Center in Tucson. Dr. Mackstaller has served on the Board of the American Heart Association, the Sarver Heart Center Advisory Board, the University Heart Center Board, the National Scientific Internal Medicine/Family Practice Advisory Board, the Hilton Head Health Institute, and the Arizona Commission on Women’s Health. Dr. Mackstaller has taught classes at the University of Arizona College of Medicine, lectured on women’s health and heart issues, and authored numerous medical journal articles. In 2003, Dr. Mackstaller received the Patients’ Choice Award from the University Medical Center in Tucson. Dr. Lefkowitz is a Fellow of the American Academy of Ophthalmology and a member of the Arizona Medical Association and the Arizona Ophthalmological Society, as well as both the American and European Societies of Cataract and RefracPage 5 ARIZONA MEDICAL BOARD MEMBERSHIP Paul M. Petelin, Sr., M.D., is a Boardcertified Surgeon in private practice in Phoenix. He received his medical degree from Creighton University School of Medicine in Omaha, Nebraska, and has a Bachelor’s Degree in Chemistry from Gonzaga University in Spokane, Washington. Dr. Petelin completed his internship and residency at St. Joseph’s Hospital and Maricopa Medical Center in Phoenix. From 1984 to 1988 and again from 2000 to 2004, Dr. Petelin was Chief of Surgery at St. Joseph’s Hospital. He is in his second term as governor of the State of Arizona American College of Surgeons. He is a member of the Board of Directors of the Phoenix Surgical Society, and is a past president of that organization. He also serves on the Board of Directors of the Arizona Medical Association. Germaine Proulx, a public member, is a certified Pharmacy Technician who lives in Sedona with her family. She has been very involved in her community since she and her husband moved there in 1977. Mrs. Proulx is a graduate of Scottsdale High School and attended Northern Arizona University in Flagstaff. Amy J. Schneider, M.D., FACOG, is a Board-certified Obstetrician-Gynecologist in Tucson where she is the Medical Director and Partner in Grace Maternity & Women’s Health. She has held an Arizona medical license since 2001. Dr. Schneider received her medical degree from Tulane University School of Medicine in New Orleans in 1997. She did her internship and residency at the Department of Obstetrics and Gynecology at the University of Arizona Health Sciences Center in Tucson. She earned her Bachelor of Science Degree from the University of Oregon. Dr. Schneider is a member of the Physicians Leadership Group at Northwest Hospital in Tucson and a member of the Tucson Society of Women Physicians. Mrs. Proulx has served on the Board of Directors for the Sedona Adult Community Center and helped establish the Meals on Wheels program. She has served as President of the West Sedona PTA and as a Girl Scout leader. She has been a member of the Parish Council at St. John Vianney Catholic Church where she is on the Finance Committee. She has also served on the Joint Legislative Committee on Hunger. Page 6 BOARD ACCOMPLISHMENTS The Arizona Medical Board had a productive year in terms of approving new rules and guidelines and launching online license renewals. In December 2007, the Governor’s Regulatory Council approved the Board’s Office-Based Surgery Rules for physicians who perform surgical procedures in their offices using sedation. The rules, which went into effect in January 2008, are meant to improve patient safety without limiting access to procedures that can be done safely in an office setting. Although there are minimum requirements involving equipment and the training of staff in administering and monitoring conscious sedation, the Board does not license and does not pre-approve a facility for Office-Based Surgery. In February 2008, the Board approved new Scope of Practice guidelines to assist physicians who make the decision to undertake new procedures, employ new technologies or migrate into new areas of medical practice for which they have not received formal post-graduate/residency training. The guidelines list a number of factors physicians should consider before engaging in an expanded practice, including the following: the clinical knowledge, judgment and skills required in order to provide services safely and competently; the education received and whether it meets the standards and is recognized by an independent and formally accredited education organization or institution; and whether the expanded scope of practice is appropriate for the education and training received. Working in concert with the Arizona Regulatory Board of Physician Assistants, the Board adopted guidelines for physicians who supervise PAs. The guidelines reflect how the two Boards will harmoniously apply the statutes when considering cases involving PA supervision. At its June 2008 meeting, the Board approved Substantive Policy Statement #13 which explains the agency’s current approach to the legal requirement that hospitals, outpatient surgical centers and physicians report peer review/quality assurance information. It identifies what constitutes reportable information, when that report is required, and who shall make the report. Early in the fiscal year, the Board adopted guidelines for Complementary and Alternative medicine to help physicians who may wish to provide such treatments and medications to their patients. The Arizona Medical Board and the Arizona Board of Osteopathic Examiners in Medicine and Surgery jointly purchased a new database specifically designed for government regulatory agencies. The GLSuite software provides a single platform for case management and reports and allows the Board to accept online license renewals. Online initial license applications will be accepted in the next fiscal year. Passage of a bill by the Second Regular Session of the 48th Arizona Legislature allows the Board to include an online quiz about the Medical Practice Act in the initial license and renewal processes. Page 7 LICENSING The Arizona Medical Board now has more than 19,600 physicians licensed to practice medicine; approximately 12,500 have Arizona office addresses. The Board received fewer applications for new licenses during the 2008 fiscal year. Some physicians who are licensed here, but are practicing in other states, did not to renew their Arizona licenses. And, as the average age of the physician workforce continues to rise, more doctors have retired. The number of initial licenses issued by the Board during the 2008 fiscal year did not meet projections, finishing almost nine percent lower than the year before. Not funded by tax dollars, the Board relies on the $500 biannual licensure fees to pay for its licensing, investigative and administrative functions. More residency positions were filled, re- sulting in the issuance of slightly more Post Graduate Training Permits. There were 20% fewer miscellaneous medical licenses issued by the Board during FY2008, but nearly a 20% increase in the number of Dispensing Certificates. The Board conducts primary source verifications on educational and training programs in initial license applications and performs national queries to determine if a physician has any professional conduct issues in other states. Although providing the proper documents is the responsibility of each applicant, Board Staff help physicians with the verification process to reduce the overall timeframe for licensure. Licenses Issued FY 07 FY08 Licenses Issued 1,458 1,328 Post Graduate Training Permits Issued 1,248 1,260 Miscellaneous Licenses Issued 92 71 Dispensing Certificates Issued 428 512 Average Number of Days to Issue a License (Date of receipt of fully 1.1 2 Customer Satisfaction Rating 99% 95% completed application to final approval) Page 8 REGULATION The Arizona Medical Board regulates the allopathic medical profession, those physicians who are MDs. The complaint process is structured to ensure a fair and impartial investigation to resolve cases in a timely fashion. When an investigation substantiates a violation of the Medical Practice Act, the Arizona Medical Board uses its authority to discipline a licensee. In the end, the Board is bound by its charge to protect Arizona citizens from the unlawful and incompetent practice of medicine. The actions the Board takes are reflective of that mission. Disciplinary actions taken against a licensee are public. Since the effect these actions can have on a physician are long-lasting, the Board takes all complaints against physicians seriously. Its decisions to issue a disciplinary order in quality of care cases are based on a review of the community standard of care. Overall, the Board took disciplinary action in 117 cases (see chart below) during FY 08. In 28 other cases, the Board ordered non-disciplinary measures for physicians such as practice limitations based on health problems, in addition to the 127 cases that resulted in the issuance of nondisciplinary Advisory Letters. FY 08 Board Disciplinary Actions 70 58 60 50 40 30 20 23 15 12 10 3 6 0 Loss of License Practice Decree of Letter of Restriction Censure Reprimand Probation License Denial Page 9 REGULATION The Arizona Medical Board’s regulatory activity most often begins when a complaint is received and an investigation is opened. The Board opens an investigation only when a complaint meets two criteria: it involves an allopathic physician and the allegation—if true— would be a violation of the Medical Practice Act. The caseload of open investigations rose about 12% during FY 2008, but stayed within an average of 350-400 cases during most of the year. Investigations Remaining Open at Fiscal Year End Year Number 2007 326 2008 489 When the investigational process was restructured in 2005, the caseload was expected to stabilize somewhere in that range. Board Staff managed to keep pace with the higher caseload without sacrificing the quality or adding to the average length of the investigations. The FY2008 average to complete an investigation Average Days to Complete an Investigation Year Days 2007 119 2008 115 continued to improve and was well below the Legislative goal of 180 days. Compliance Monitoring is the Board’s method for ensuring physicians obey Board orders. The Compliance figure represents the number of physicians being monitored for these reasons. Compliance officers conduct random practice audits, review physician records and report to the Board any findings of non-compliance. Failure to follow a Board order can lead to more disciplinary action. Compliance Monitoring Type Cases Monitored Compliance 178 MAP 89 Other PHP 36 Additionally, licensees in the Board’s Physician Health Program (PHP) may be in either the Monitored Aftercare Program (MAP) for substance abuse rehabilitation or in the “other” part of the PHP for medical, psychiatric, psychological or behavioral health issues. PHP coordinators ensure that physicians comply with the program’s requirements and are safe to practice medicine. Findings of non-compliance are immediately brought to the agency’s attention. Page 10