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Perez v. Tennessee Board of Medical Examiners

Court of Appeals of Tennessee, Nashville

July 3, 2019

ANDRES PEREZ
v.
TENNESSEE BOARD OF MEDICAL EXAMINERS

          Session May 8, 2019

          Appeal from the Chancery Court for Davidson County No. 16-1218-III Ellen H. Lyle, Chancellor

         This case arose out of the Petitioner/Appellant's attempts to become a licensed physician in Tennessee. Appellant sent an application to the Tennessee Board of Medical Examiners but was ultimately rejected. After a contested hearing, the Board again determined that Appellant's application should be rejected since Appellant had not engaged in direct patient care in many years. Thereafter, Appellant sought review of the Board's decision in the Chancery Court of Davidson County pursuant to the Tennessee Uniform Administrative Procedures Act. The chancery court concluded that Appellant was not entitled to relief, and Appellant appealed to this Court. Discerning no error, we affirm.

         Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Chancery Court Affirmed

          David R. Grimmett, Nashville, Tennessee, for the appellant, Andres Perez.

          Herbert H. Slatery, III, Attorney General and Reporter; Sara E. Sedgwick, Senior Assistant Attorney General; Nicholas R. Barry, Assistant Attorney General, for the appellee, Tennessee Board of Medical Examiners.

          J. Steven Stafford, P. J., W.S., delivered the opinion of the court, in which Kenny Armstrong and Carma D. McGee, JJ., joined.

          OPINION

          J. STEVEN STAFFORD, JUDGE

         Background

         This case involves the efforts of Dr. Andres Perez ("Appellant") to become a licensed Tennessee doctor certified to practice emergency and general medicine.[1] Appellant graduated from medical school in 1981 and thereafter participated in various residency programs throughout the northeastern United States. It is undisputed that Appellant never fully completed a residency program, but did practice in the areas of general surgery as well as emergency medicine for several years. From 1988 through 1999, Appellant practiced emergency medicine and eventually became fully licensed in Michigan, Arizona, and New Hampshire. Starting in 1999, however, Appellant ceased working directly with patients and was employed at various private healthcare companies. Appellant became board certified in preventative medicine and from 1999 to September 2006, Appellant was employed with Blue Cross Blue Shield. Then, from September 2006 through April 2015, Appellant worked for Healthways, Inc.[2] in Franklin, Tennessee.

         On May 22, 2015, Appellant filed an application with the Tennessee Board of Medical Examiners ("the Board") for medical licensure in the State of Tennessee, requesting to be certified in emergency medicine and general practice. Thereafter, Appellant received correspondence from the Board revealing the Board's concern that Appellant had not practiced emergency medicine since 1999 and requested that Appellant interview with the entire Board.[3] The interview took place on January 26, 2016, and the Board thereafter voted to deny Appellant's application for medical licensure. In a follow-up letter sent to Appellant, the Board indicated that Appellant's application was denied "in light of the fact that you have been out of clinical practice for the past sixteen years." This letter also provided that Appellant was entitled to challenge the Board's ruling in a contested hearing pursuant to Tennessee's Uniform Administrative Procedures Act ("the UAPA") should Appellant so choose.

         Consequently, Appellant filed an appeal of the Board's decision and a contested case hearing was set for September 14, 2016. At the hearing, Appellant testified that although his preventative medicine practice with insurance companies did not involve any direct patient care, he was heavily involved in the reviewing of patients' charts and in working with healthcare providers to create and modify care plans for patients. In Appellant's own words, he described this position as

[t]he utilization review and utilization management . . . both at the hospital level and also at the individual's private practice level. In both instances I would review the charts of the patients for the assessment and the working diagnosis, and identify - - I would be looking for appropriate flow of the evaluation process, the use of corroborative testing or the lack of, and would be providing some information to the providers and to the facilities in terms of the performance of care, the administration of care on these patients.

         Overall, Appellant's testimony reflected that his duties were largely administrative, although they did involve some level of diagnosing patients and collaborating with providers to create treatment plans. Further, Appellant discussed how since learning of the Board's concern regarding Appellant's long absence from clinical practice, Appellant had begun to seek out opportunities to reintegrate himself into the practice of emergency medicine. Specifically, Appellant participated in a one-month emergency medicine rotation at St. Mary Mercy Hospital in Michigan in March-April of 2016 and in July of 2016 Appellant began working in the Ireland Army Community Hospital in Fort Knox, Kentucky as an emergency medicine staff physician. Appellant entered into evidence letters of recommendation from both of the doctors that had supervised Appellant in these recent positions; the letters were complimentary of Appellant and suggested that he would be a strong addition to the medical community in Tennessee. Appellant also testified, however, that the last time he was solely and independently responsible for a patient's care, including diagnosis, treatment, and/or writing prescriptions was in 1999.

         At the end of the contested hearing, the Board determined that Appellant should not be granted medical licensure in Tennessee due to his long absence from emergency medicine. The Board's final order, in pertinent part, stated as follows:

3. [Appellant] holds active, unencumbered medical licenses in Michigan and Arizona and an inactive license in New Hampshire.
4. [Appellant] practiced emergency medicine from 1988 until 1999 and has not engaged in direct patient care since that time. From 1999 until approximately September 2006, [Appellant] practiced administrative medicine with Blue Cross Blue Shield. Since approximately September 2006 until at least April 2015, [Appellant] was employed by Healthways, Inc. in Franklin, Tennessee without benefit of a medical license.
5. Based on the foregoing, [Appellant] was asked to appear for interview before the Board and did so appear on January 26, 2016. During this interview, [Appellant] acknowledged that he had not seen a patient or practiced clinical medicine since 1999. Prior to denial, [Appellant] was given ample opportunity to withdraw his application. Based on the application and the interview, the Board voted to deny [Appellant's] application.
7. The facts alleged in paragraphs 1 through 6, supra, would constitute grounds for denial pursuant to TENN. CODE ANN. § 63-6-10l(a)(3) which provides that it is "the board's duty to examine the qualifications of all applicants for certification of fitness to practice medicine or surgery in this state . . ."
8. The facts alleged in paragraphs 1 through 6, supra, would constitute grounds for denial pursuant to TENN. CODE ANN. § 63-6-214(a) which gives the board the power to deny an application for a license to any applicant who applies for the same through reciprocity or otherwise.

         Thus, although the Board strongly commended Appellant for taking steps towards reintegration into emergency medicine, the Board ultimately took the position that four months of working in the emergency room under the supervision of other doctors could not remedy the extended lapse in Appellant's emergency medicine practice. Nonetheless, the Board also stated that should Appellant complete a formal assessment that reflected that he is "fit and safe to practice without further remediation" within one year, Appellant could be granted a Tennessee license.

         Pursuant to the UAPA, Appellant thereafter sought judicial review in the Chancery Court of Davidson County, Tennessee ("trial court") by filing a timely petition for review of the Board's action. In Appellant's brief to the trial court, he outlined four arguments: (1) that the Board's findings of fact and conclusions of law were insufficient for meaningful appellate review; (2) that the Board used an improper procedure in the contested case hearing in that it applied a presumption of "clinical incompetence" due to Appellant's extended absence from emergency medicine, and that this presumption was an unconstitutional procedure; (3) that the Board's decision to deny Appellant medical licensure violated the public policy of Tennessee; and (4) that the Board's decision was unsupported by the evidence in light of the fact that Appellant is licensed in three other states. In response, the Board asserted that the burden of proving competency such that licensure was appropriate lay with Appellant, and that Appellant could not establish that the Board's decision was arbitrary and capricious or unsupported by the evidence at the hearing. The trial court held a hearing on April 5, 2018, after which it determined that Appellant's petition should be denied.

         A written order was entered by the trial court on April 23, 2018. Therein, the trial court made detailed findings as to each of Appellant's four arguments. First, the trial court ruled that the Board's findings of fact and conclusions of law were sufficient to facilitate appellate review because the conclusions refer back to the findings upon which the conclusions are based. Stated differently, the trial court found that the Board exercised its discretion to deny Appellant licensure in light of Appellant's extended absence from any employment involving direct patient care. In the trial court's view, this was clearly reflected in the Board's final order, specifically paragraphs four and five. As such, the trial court soundly rejected Appellant's assertion that review of the instant case was not possible based on the format of the Board's order. Next, the trial court also rejected the contention that the Board engaged in any improper procedures during Appellant's contested case hearing. In addressing Appellant's third and fourth arguments, the trial court concluded that the Board did not violate public policy in denying Appellant's petition, and that substantial and material evidence underpinned the Board's decision.

         Appellant filed a timely notice of appeal to this Court on May 23, 2018.

         Issues ...


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