the interplay of administrative dental license discipline and dental malpractice professional...
TRANSCRIPT
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Greetings from San Francisco!
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The Interplay of Administrative Dental License Discipline And Dental Malpractice
PROFESSIONAL LIABILITY DEFENSE FEDERATION
2013 Annual MeetingChicago, Illinois
Presented byWilliam Manning, Esq.
Van De Poel, Levy & Allen, LLP
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This Will Be Over In A Flash!
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There Will Be A Test.Don’t Fail.
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Course Objectives
Understanding the Profession
The Regulatory Scheme
The Disaster Of Discipline
Overview Of Administrative Discipline Process
Punishment – “this won’t hurt much”
Insurance – manna from heaven
Maximizing Defense Of Malpractice Case To Mitigate Or Avoid Disciplinary Risk
RBA101 For The Legal Practitioner
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A Profession In Transition
“It is a critical moment for dentistry and a time for the profession to define its destiny. Given the significant environmental changes on the horizon, this is a watershed moment for the profession.”
American Dental Association, August 2013
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The Onslaught Of Lawyers
ABA TASK FORCE ON THE FUTURE OF LEGAL EDUCATION:
44,258 new law graduates in 2010
78,900 applicants for 2012
High student debt
Few jobs = more solos
P.S. - oversupply of Dentists
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“You’re Kidding!?”
Hungry lawyers + even hungrier clients in difficult economic times mean no case is too small.
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Diastema
• dī'ə-stē'mə• “An abnormal space between two adjacent
teeth in the same dental arch.” Mosby’s Dental Dictionary 1998
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Truth Is Stranger Than Fiction
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Let’s Get Started
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Dentistry: Dictionary
“The science and art of preventing, diagnosing, and treating diseases, injuries, and malformations of the teeth, jaws, and mouth and of replacing lost or absent teeth and associated structures.” Mosby’s Dental Dictionary 1998
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Dentistry: Statutory
“Dentistry is the diagnosis or treatment, by surgery or other method, of diseases and lesions and the correction of malpositions of the human teeth, alveolar process, gums, jaws, or associated structures; and such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation.” California Bus. & Prof. Code §1625
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D.D.S. or D.M.D. - What It Takes
Four Years of College
Four Years of Dental School
National Boards
Practical Exams
Residency
Specialization
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Understanding The Profession
Practice 30 + years bent over with an aching back while holding a 100,000RPM diamond burr handpiece with patient gagging and spitting in your face.
Then you get sued.
Or worse.
Or prison.
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License Regulation
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Overview Of License Regulation
Statutory/Regulatory
Common Law – all but 8 states
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Overview Of License Regulation
“Any licentiate may have his license revoked or suspended or be reprimanded or be placed on probation …
…for unprofessional conduct, or incompetence, or gross negligence, or repeated acts of negligence … or for any other cause … in this chapter.” California Bus. & Prof. Code§ 1670
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Overview of License Regulation
Statutory Authority
“Dental/Dentistry Practice Act”
“Health Occupations Revision Act” (D.C.)
“The Dental Law” (PA)
“Act 368” (MI)
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Overview of License Regulation
Licensing Agencies
“Board of Dental Examiners”
“Dental Board”
“Dental Commission” “Department of Financial and Professional Regulation Division of Professional Regulation”(IL)
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Overview Of License Regulation
Department Of Consumer Affairs
Dental Board of California
8 practicing DDS
1 RDH
1 RDA
5 Public
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Priority: Protection Of The Public
“Protection of the public shall be the highest priority for the Dental Board …[if] inconsistent with other interests … the protection of the public shall be paramount.”
California Bus. & Prof. Code §1601.2.
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Priority: Protection Of The Public
“The purpose of disciplinary proceedings
… is not to punish the professional but is rather to protect the public from further wrongdoing.
In re Appeal of Schramm, 414 N.W.2d 31 S.D. (1987)
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Stormy Weather
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License Discipline: What Is The Risk?
Unmitigated Disaster
No Such Thing As A “Little” Discipline
Reputational Loss
Emotional And Psychic Impact
A Different Standard: Professionals
Lawyers vs. Doctors
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Nightmare In The Dental Chair
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Nightmare in the Dental Chair
People v. Griswold
Board v. Griswold
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Professionals: A Different Standard
“If there is one unique area of …law where strict compliance with protocol and military like discipline is required, it is in the medical field. Human lives depend on it…”
Ress v. Abbott Northwestern Hospital, Inc., 448 N.W.2d 519 (MN, 1989)
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No Such Thing As A “Little” Discipline
“Revocation of a dentist's license is the ultimate penalty which can be applied, for it terminates his ability to practice in a specialized discipline to which he has devoted years of preparation…”
Kundrat v. Commonwealth State Dental Council & Examining Bd., 67 Pa. Commw. 341 (1982) [Dissenting Op.]
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License Discipline: Financial Loss
Loss Of Privileges = Loss Of Business
PPO
HMO
Traditional Indemnity
Private Pay
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License Discipline: Insurability
Loss of Top Coverage
High Risk Category
Lower Limits
More costly
No Discipline Coverage
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License Discipline: Reputation
Obligation to truthfully admit discipline
Word of mouth
Yelp et. al.
Public Records Act
Internet access to Board website
Public while pending
Cf: confidential while pending?
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License Discipline: Reputation
“Disciplinary proceedings against a licensed dentist are confidential until the Board officially rules against the dentist and releases its findings and imposition of discipline.”
La. State Bd. of Dentistry v. DDS, 18 So. 3d 792 (2009)
Guilty until proven innocent!
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License Discipline: Disclosure
“Given the procedural posture in which this case reaches us, we will assume, but need not decide, that Dr. Mendel owed [patient] a duty to disclose ‘multiple’ suspensions or revocations; reprimands by ‘numerous’ dental review boards; or suspensions or revocations in ‘numerous’ states.”
Ex Parte Mendel, 942 So. 2d 829 (Ala. 2006)
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Sources Of Administrative Investigations
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Sources: Patient Complaints
Obligation To Investigate Complaint
Disgruntled Patients
Billing Disputes
Insurance Dilemmas
Plaintiff’s Attorneys
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Sources: Third Party Reports
Public Agency
Other Professions
Colleagues
Disgruntled Employees
Peer Review Issues
805 Reports
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Sources: Malpractice
Malpractice Settlements
By Insurer
By Uninsured Doctor
Malpractice Judgments
By Clerk of Court
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Sources: Malpractice
“Notably, an inquiry from an insurance representative launched the board's investigation into his license status.”
Hagen v. Iowa Dental Bd., 2013 Iowa App. LEXIS 978
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Sources: NPDB Reports/Inquiries
Purpose: "restrict the ability of incompetent [health care professionals] to move from State to State without disclosure or discovery of the [professional's] previous damaging or incompetent performance." 42 U.S.C. § 11101(2)
No Threshold
Insurer Report
Query: Future Public Accessibility
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Reporting Limits By State
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Bases Of Discipline
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Bases of Discipline: Criminal
“Clearly, a defendant does not have to be told of all the numerous possible collateral consequences of a guilty plea in order for that plea to be legally permissible, proper, and binding.”
Caudill v. Ky. Bd. of Dentistry, 2006 Ky. App. Unpub. LEXIS 814
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Bases of Discipline: Criminal
“Dr. Smith was convicted on a plea of nolo contendere of two counts of assault stemming from incidents in which he improperly administered anesthesia, allegedly leading to the death of two patients.”
State v. Smith, 593 P.2d 625 AK (1979)
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Bases of Discipline: Criminal
Nolo Contendere plea to felony, or of any misdemeanor substantially related to the qualifications, etc. is deemed to be a conviction -- irrespective of later plea withdrawal
California Bus. & Prof. Code § 1018.05.
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Bases of Discipline: Criminal
“The sole reason for the Board’s decision was Caudill’s criminal conviction of a crime involving moral turpitude.”
Caudill v. Ky. Bd. of Dentistry, 2006 Ky. App. Unpub. LEXIS 814
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Bases of Discipline: Criminal
Conviction Of Crime:
“substantially related to the qualifications, functions, or duties”
“record of conviction …shall be conclusive evidence”
Felony Conviction
California Bus. & Prof. Code § 493
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Bases of Discipline: Criminal
“At the formal hearing on January 6, 1992,
McGrath reaffirmed his position, stipulating that he had been found guilty of the [Medicare] fraud charges but requesting that, to avoid possible injustice in the event of a subsequent acquittal, the SBOD defer its adjudication on his license until final judgment was entered in his criminal appeal.”
McGrath v. State Bd. of Dentistry, 159 Pa. Commw. 159 (1993)
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Bases of Discipline: Criminal
“Clearly excessive…
prescribing, furnishing, dispensing, or administering.”
Misdemeanor
fine: $100 --$600
imprisonment: 60 -180 days
both
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Bases of Discipline: Criminal
Aiding and Abetting
Sule v. Guam Bd. of Dental Examiners, 2008 Guam 20
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Bases of Discipline: Criminal
A DDS and His Gun
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Bases of Discipline: Addiction
“Prescription drugs follow alcohol as the most commonly abused substances by lawyers seeking help through state support programs.”
ABA Commission on Lawyer Assistance Programs (2013)
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Bases of Discipline: Addiction
Addiction Issues
“The Other Bar”
Diversion Programs
Reality Check
Require New License Application
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Bases of Discipline: Addiction
“Dr. Brown had not been practicing since March 1993, a little over two years …substantial evidence existed indicating Dr. Brown had not maintained his skills…”
Brown v. State Dep't of Health, Dental Quality Assur. Comm'n, 1997 Wash. App. LEXIS 1166
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Bases of Discipline: Sexual Misconduct With Patient
Lawyers
Judges
Healthcare professionals
Proscription:
“any act of sexual abuse, misconduct, or relations”
“patient, client, or customer”
Exceptions
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Bases of Discipline: Sexual Misconduct With Patient
“The basis of the Board’s order was …[Dentist] was guilty of unprofessional conduct by making ‘lewd lascivious, and improper advances to a patient.’ There [were] two separate incidents involving different patients. The Board may not make eight separate offenses out of two incidents. ‘Lewd’ and ‘lascivious’ are synonymous, and both may be considered ‘improper.’ We remand …”Jensen v. Board of Dental Examiners, 53 Ore. App. 50 (1981)
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Bases of Discipline: Sexual Misconduct With Patient
Board of Registration in Dentistry found “the parties had been engaged in a mutually enjoyable sexual relationship …” but concluded that consent would not exonerate the dentist. Magistrate recommended revocation. Actual suspension.
Roe v. Federal Ins. Co., 412 Mass. 43 (1992)
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Bases of Discipline: Sister State Discipline
“Where, as here, charges of serious professional misconduct have been brought before the licensing board of a foreign jurisdiction, and the professional is afforded the full opportunity to challenge the truth of those allegations but has chosen to waive that opportunity, and to resolve the complaints by agreeing to discipline, we see no need for the Massachusetts board to take on the burden of conducting an out-of-State investigation, and attempting to prove those allegations in order to impose reciprocal discipline.”
Anusavice v. Bd. of Registration in Dentistry, 451 Mass. 786 (2008)
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Bases of Discipline: Continuing Education
“The first count alleged that Mostatab was subject to disciplinary action…for violating…regulations [re] reporting continuing education credits….”
“The second count alleged that Mostatab was subject to discipline …in that she made a false or deceptive biennial renewal with the Board.”
Mostatab v. State Bd. of Dentistry, 881 A.2d 1271 (Pa. Commw. Ct. 2005)
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Bases of Discipline: Deceptive Advertising
“[T]he advertisements were misleading because of the possibility that a lay person would conclude that "polydontics" was a dental specialty and that Dr. Barnett possessed some special expertise not held by most general practitioners.
Barnett v. Maryland State Bd. of Dental Examiners, 293 Md. 361 (1982)
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Bases of Discipline: Clinical Allegations
Repeated Acts of Negligence
Gross Negligence
Gross Violation of SOC
Incompetence
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Bases of Discipline: Repeated Acts of Negligence
“Departure from standard of care.”
Repeated Acts of Negligence
= more than one
James v. Board of Dental Examiners (1985) 172 Cal. App. 3d 1096
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Bases of Discipline: Gross Negligence
“An extreme departure from the accepted standards of care of
dental practitioners.”
James v. Board of Dental Examiners (1985) 172 Cal. App. 3d 1096
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Bases of Discipline: Incompetence
“Incompetence generally is defined as a lack of knowledge or ability in the discharging of professional obligations.”
James v. Board of Dental Examiners (1985) 172 Cal. App. 3d 1096
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Repeated Acts of Negligence
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Gross Negligence
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Incompetence
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Discipline: Exceeding Scope Of Practice*
“But in performing the elective cosmetic procedures, [Dentist] violated OCGA § 43-11-17 by exceeding the statutory limits of the scope of dentistry. Thus, we conclude that [Dentist] committed negligence per se….”
Brown v. Belinfante, 252 Ga. App. 856 (2001)
*NB: statutory definition of practice.
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Discipline: Unprofessional Conduct
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Discipline: Unprofessional ConductDifficult and growing area
Statutory
CA: double letters
“The violation of any of the provisions of this division.” California Bus. & Prof Code §1680(n)
Frequently basis for criminal liability
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Unprofessional Conduct Risk
Examples
The Smock
Kid And Dad
Lady DDS
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Overview Of Administrative Process
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Overview Of Administrative Process
Administrative Authority
Due process considerations
Emergency Revocation
Investigation Process
Accusation/Petition re Discipline
Discovery
Settlement
Pre-hearing conference
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Overview Of Investigation
Who Investigates?
“Dear Doctor” letter
Failure to comply = discipline
Board Evaluation
AG Referral
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That Visceral Feeling
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“Baggage Claim”http://av8.home.comcast.net
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Emergency Revocation
Authority
Time limits
Not always a bad thing
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Discipline Pleadings
“Petition”
“Accusation”
“OSC Alleging Violation”
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First Appearance
Response To Accusation
Tight time limits!
Notice of Defense
Affirmative Defenses
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Pleading Defenses
Affirmative Defenses: few
Amending Pro Per appearance
Waiver
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Administrative Discovery
“Discovery” is an oxymoron
Limited or Highly Limited
Tight time limits
Depositions
Dismissal For Failure To Make
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Pre-Trial Matters
Pre-hearing Conference
Settlement Conference
Settlement Terms & Conditions
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Administrative Hearing
Who hears?
Administrative Law Judge
Administrative Magistrate
Hearing Officer/Examiner
Licensing Board
Peers
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“Kangaroo Court”
“Mr. Manning’s medi-legal argument”
“Don’t bother me with the science”
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Administrative Standards of Proof
Standards of Proof: real or illusory?
Statutory
Case Law
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Administrative Standards of Proof
“The proper standard of proof in disciplinary proceedings against a person holding a professional license is clear and convincing evidence.”
“The district court was within its discretion when it ordered the members of the Board disqualified from hearing the proceeding against the appellee…”
Johnson v. Board Of Governors Of Registered Dentists Of Oklahoma, 1996 OK 41
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Defenses: Procedural/SubstantiveStatutes Of Limitation
Due Process Considerations
Standard of Care
Fact And Opinion
Waiver Issues
Importance Of Local Law
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Defenses: Statutes Of Limitation
CA - 3 years after discovery of act/omission
CA - 7years after the act or omission
Exceptions:
Fraud
Intentional concealment
Minors
Importance of local law
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Defenses: Standard of Care
Primary mode of defense
Experts Critical
Board Consultant
Board hack
Defense experts must be better
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Defenses: Expertise
“When the administrative body applies its own expertise …to set the standard of care and a determination whether a professional violated it, the appellate courts, who are lawyers by training, lack the expertise to review findings of a board concerning medical, dental or any multitude of professions and occupations.”
In re Appeal of Schramm, 414 N.W.2d 31 S.D. (1987)
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Defenses: Board Can Decide
“We can logically assume that the dentists sitting on the Board which heard the case are knowledgeable and experienced in the field of dental medicine … As such, they are permitted to draw on their expertise in ruling on matters which come before them.”
Kundrat v. Commonwealth State Dental Council & Examining Bd., 67 Pa. Commw. 341 (1982)
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Defenses: Board Can Decide
“Thus, we decline to impose a per se rule that expert testimony is required to establish the standard of care in disciplinary hearings conducted by professional licensing boards.”
Watkins v. N.C. State Bd. of Dental Exam'rs, 358 N.C. 190 (2004)
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Defenses: Fact And Opinion
Fact and opinion
Critical nature of the chart
Complete familiarity with entries
Electronic charts
Digital radiographs
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Defenses: Causation
“My son is better off.”
Lack Of Injury/Damages
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Defenses: Waiver Concerns
“Because McGrath did not raise his procedural due process argument before the SBOD, nor was he prevented from raising it there, he has waived the issue on appeal. Accordingly, we affirm the order of the SBOD.”
McGrath v. State Bd. of Dentistry, 159 Pa. Commw. 159 (1993)
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Due Process Considerations
“We agree that the term ‘appropriate monitoring equipment’ is unconstitutionally vague because it does not provide a reasonable standard by which Dr. Watkins was supposed to act. The term…is not defined in the regulation and what is ‘appropriate’ is subject to many different meanings.” Watkins v. State Bd. of Dentistry, 740 A.2d 760 (Pa. Commw. Ct. 1999)
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Due Process Considerations
“We are not convinced that the prohibition of ‘dishonorable conduct’ presents a realistic danger that protected free speech rights…will be chilled. Also, the potential … is very small in relation to the statute’s legitimate sweep in regulating professional conduct of licensed dentists … whatever overbreadth might exist should be cured through case-by-case analysis …
Wettach v. Iowa Bd. of Dental Examiners, 524 N.W.2d 168 (1994)
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Administrative Decision
Who decides?
Proposed Decision
Adopt or Non-Adopt“Not a danger to the public.”
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Administrative Deference
“District court erred concluding that [Board] erred when it failed to defer to hearing officer's determination that dentist's conduct was not unprofessional and recommendation that she not be disciplined.”
N.M. Bd. of Dental Health Care v. Jaime, 2013-NMCA-040
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Post-Hearing Relief
Jurisdiction/Timing Issues
Reconsideration
Stay
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Post-Decision Relief
Finality of Decision
Trial Court
Venue Issues
Writ
Stay
Standard of Review
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Post-Judgment Relief
Court of Appeal
Temporary Stay
Supersedeas
Standard of Review
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Remand Protocol: déjà vu all over again
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Discipline aka Punishment
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Discipline aka Punishment
“[Board] has convincingly demonstrated through testimony and documentary evidence that [Dentist] committed the acts charged and has earned the revocation sought.”
Board Closing Brief
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Discipline aka Punishment
Not Supposed To Punish—But It Does
Early 13c., "penitential chastisement;
punishment," from Old French descepline
11c.) "discipline, physical punishment;
teaching; suffering; martyrdom…"
http://www.etymonline.com/index.php
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Prior/Other Discipline
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Levels Of Discipline
Revocation
Suspension
Probation
Public Reproval
Private Reproval
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Adding Insult To Injury
Costs of Prosecution
Restitution to victim
Limited recovery to successful DDS
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Adding Insult To Injury
Dentist's action to recover costs for administrative proceedings under La. Rev. Stat. Ann. § 49:965.1 "Reasonable litigation expenses" means any expenses, not exceeding seven thousand five hundred dollars.”
Allen v. Louisiana State Bd. of Dentistry, 595 So. 2d 320 (1991)
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Other Aspects Of Discipline
Supervised practice
Monitor
Limited scope of practice
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Citations And Fines
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Terms and Conditions
Numerous
Mandatory
Admission of fault
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Judicial Review Of Discipline
“Manifest abuse of discretion.”
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Recovery
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Recovery
Avoidance
Damage Control – You Can Help!
Preparation
Letters
Recovery Proceedings
Petition To Terminate Probation
Petition To Restore License
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The Crucial Importance Of Insurance
Availability Of Coverage
Costs of legal defense
Expert costs
Increasing Use Of Sub-Limits
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The Crucial Importance Of Insurance
Need For Excess Policy
Examples
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Handling The Civil Malpractice Case To Maximize Disciplinary Defense
OPM
Expectation Of Discipline
Restrictions On Discovery In Discipline Case
Preparing Experts
Framing The Outcome In Advance
Post-trial Proceedings
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Handling The Civil Malpractice Case To Maximize Disciplinary Defense
Conflicts of Interest
ACO
Hospitalists
Kaiser
Liability Insurers
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Ancillary Matters
805 Reports And Proceedings
Denial Of License
Surrender In Lieu
Restoration/Reinstatement
Proceedings To Terminate Discipline
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RBA101 For The Legal Practitioner
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RBA101 For The Legal Practitioner
“Risks, Benefits, And Alternatives”
Informed (Legal) Consent
CYA
Legal Malpractice Issues re RBA
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RBA101 For The Legal Practitioner
Settlement Of Civil Malpractice Cases
Policy
Statutory
Hammer Clauses
Excess and Surplus Lines
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RBA101 For The Legal Practitioner
Settling a dental malpractice case can result in significant adverse consequences for the dental licentiate. A defense to and including trial and appeal may be required to achieve a settlement or judgment less than the licensing agency reporting limits, to protect the dentist from the devastation of discipline, or prepare for it.
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Course Summary
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Course Summary
Dentistry And How It Is Regulated
The Disaster Of License Discipline
How Administrative Discipline Begins
Authority And Scope Of Discipline
Overview Of Administrative Discipline Process
Punishment
The Role Of Insurance
Maximizing Defense Of Malpractice Case To Mitigate Disciplinary Issues
RBA101 For The Legal Practitioner
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Q&A
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I’m Outta HereThank You Very Much!